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Differential   Diagnosis 

VOLUME  II 

PRESENTED    THROUGH 

AN   ANALYSIS   OF  317   CASES 


BY 


RICHARD   C.   CABOT,   M.  D. 

ASSISTANT  PROFESSOR  OF  CLINICAL    MEDICINE,   HARVARD     UNIVERSITY    MEDICAL    SCHOOL,    BOSTON 
CHIEF   OF  THE   WEST  MEDICAL    SERVICE 


MASSACHUSETTS  GENER.\L  HOSPITAL 


PROFUSELY  ILLUSTRATED 


PHILADELPHIA    AND    LONDON 


W.   B.    SAUNDERS    COMPANY 

1914 


Copyright,  IQ14,  by  W.  B.  Saunders  Company 


PRINTED     IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


PREFACE 


The  first  volume  of  this  work  dealt  with  the  symptom  pain,  and 
with  eleven  other  common  symptoms.  In  the  present  volume  the 
same  plan  has  been  carried  further.  Nineteen  other  symptoms  have 
been  selected,  analyzed,  and  illustrated.  I  have  profited  much  from 
the  study  of  the  Index  of  Differential  Diagnosis,  by  Herbert  French 
and  other  writers,  an  admirable  book  published  in  191 2,  since  my 
first  volume  appeared.  To  the  writers  of  that  book  I  gratefully 
acknowledge  my  indebtedness. 

As  in  the  previous  volume,  I  have  received  very  substantial  help 
from  Dr.  James  H.  Young,  and  from  my  secretaries.  Miss  Alice 
O' Gorman,  Miss  Mary  F,  Foote,  and  Miss  Florence  Painter. 

R.  C.  C. 

I  Marlborough  St.,  Boston,  Mass. 

December,  1914. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/differentialdiag02cabo 


TABLE   OF   CONTENTS 


CHAPTER   I 

ABDOMINAL  AND   OTHER  TUMORS 

Page 

General  CoNsroERAxioNS 17 

Case  No. 

1.  Pregnancy 27 

2.  Echinococcus  Cyst  of  Liver 28 

3.  Adenocystoma  of  Ovary;  Thrombosis  of  Vena  Cava  Inferior 29 

4.  Myeloid  Leukemia 31 

5.  Nephroptosis;  Congenitally  Deformed  Kidney;  Corset  Lobe  of  Liver 34 

6.  (a)  Hypernephroma  (?) ;  {b)  Cervical  Rib 37 

7.  Osteitis  Deformans 39 

8.  Pelvic  Cancer,  probably  Ovarian 41 

9.  Malignant  Lymphoma  (Lymphoblastoma — Mallory) 45 

10.  Hydronephrosis 49 

11.  Glanders 52 

12.  Phantom  Tumor 65 

13.  Malignant  Lymphoma  of  the  Retroperitoneal  Glands  (Lymphoblastoma — 

Mallory) 68 

14.  Axillary  Abscess 69 

15.  Lymphoid  Leukemia 70 

16.  Lymphoid  Leukemia;  Abdominal  Masses  and  Ascites 72 

17.  Cancer  of  the  Tail  of  the  Pancreas  with  Extension  to  the  Spleen,  Liver, 

and  Glands 74 

18.  Multiple  Lipomata 76 

19.  Extra-uterine  Pregnancy 77 

20.  Gumma  of  Thigh 79 

21.  Tuberculous  Peritonitis 80 

22.  Cancer  of  the  Cecum 85 

23.  SyphiUs 86 

24.  Malignant  Lymphoma  (Hodgkin's  Disease,  Mallory's  Lymphoblastoma)..  88 

25.  Aortic  Aneurysm 92 

26.  Syphilis 93 

27.  Syphilitic  Gumma  of  the  Sternum 95 

28.  Gumma  of  the  Frontal  Bone 97 

29.  Gastric  Cancer 99 

30.  Gastric  Cancer  with  Metastasis  in  a  Supraclavicular  Lymph  Node loi 

31.  Sj^hilis 104 

32.  Syphilitic  Periostitis  of  Cranial  Bones 106 

33.  Chronic  Family  Jaundice  (Hemolytic  Jaundice) no 

34.  Cancer  of  the  Cecum  and  Appendix 115 

$5.  Walled-off  Abscess  about  Gall-bladder 116 

36.  Kidney  Stone;  Pyonephrosis 119 

7 


8  TABLE    OF    CONTENTS 

Case  No.  Page 

37.  Phantom  Tumor 121 

38.  Melanotic  Sarcoma  of  Liver 1 23 

39.  Hji^emephroma 126 

40.  Lymphoblastoma 127 

41.  Echinococcus  of  Liver 131 

CHAPTER   II 

VERTIGO 

General  Considerations 134 

Physiologic  Vertigo 134 

Pathologic  Vertigo 136 

Is  There  a  Gastric  Form  of  Vertigo? 139 

Case  No. 

42.  Chronic  Nephritis  in  an  Excessive  Smoker 139 

43.  Aneurysm  of  the  Thoracic  Aorta 140 

44.  Chronic  Interstitial  Nephritis  (Arteriosclerotic  Type);  Uremia 142 

45.  Endothelioma  of  the  Dura  in  the  Posterior  Fossa  of  the  Skull 144 

46.  T>T3hoid  Fever 146 

47.  Labyrinthine  Disease 147 

48.  Addison's  Disease 147 

49.  Heat  Stroke 150 

50.  Alcohohsm;  Cirrhosis  (?);  Syphilis  (?) 151 

51.  Chronic  Glomerular  Nephritis 152 

52.  Hysteria  in  a  Syphilitic 153 

53.  Cerebellar  Cyst;  Arteriosclerosis 154 

54.  Cerebral  Syphilis iSS 

55.  Cerebral  Syphilis 156 

56.  Miliary  Tuberculosis  with  Tuberculous  Meningitis 159 

57.  Myocardial  Weakness;  Arhythmia 160 

58.  Arteriosclerosis 162 

59.  Addison's  Disease .  » 163 

60.  Arteriosclerosis 165 

61.  Cerebellar  Tumor 1 167 

62.  Miliary  Tuberculosis 168 

63.  Meniere's  Disease 170 

64.  Syphilis 172 

65.  Otosclerosis;  Labyrinthitis i73 

CHAPTER   III 

DIARRHEA 

General  Considerations 1 75 

Causes  and  Types  of  Diarrhea  in  Adult  Life 175 

Difficulty  of  Distinguishing  Acute  from  Chronic  Enteritis  and  Colitis.  ...  176 

Causes  of  Diarrhea 178 

Types  and  Diagnosis 183 

Case  No. 

66.  Pericecal  Tuberculosis 185 

67.  Tuberculous  Enteritis 187 

68.  Fat  Intolerance;  Abdominal  Tumor  (Lymphoblastoma?) 189 

69.  Neurasthenia ^93 

70.  Cancer  of  the  Bladder i94 


TABLE    OF    CONTENTS  9 

Case  No.  .  Page 

71 .  Appendix  Abscess 197 

72.  Tuberculous  Peritonitis  and  Enteritis 198 

73.  Infectious  Colitis;  Otitis  Media 200 

74.  Cancer  of  the  Sigmoid 201 

75.  General  Infection  due  to  Bacillus  Coli;  Typhus  Fever 202 

76.  Meddlesome  Surgery 204 

77.  Food  Diarrhea 206 

78.  Tuberculous  Peritonitis 208 

79.  Chronic  Colitis;  Starvation 211 

80.  Colitis  of  Unknown  Cause 214 

81.  Chronic  Diarrhea  from  Bad  Habits 215 

82.  Chronic  Colitis  (Tuberculous?) 216 

83.  Chronic  Glomerular  Nephritis  and  Acute  Endocarditis 220 

84.  Amebic  Dysentery 223 

85.  Bilharziasis 225 

86.  Plumbism;  Tabes;  Morphinism 227 

87.  Pernicious  Anemia 230 

88.  Pernicious  Anemia 233 

89.  "Leather-bottle  Stomach"  (Diffuse  Carcinoma)  with  Cancerous  Peritonitis  235 

90.  Stricture  of  Rectum  (Syphilitic?) 237 

91 .  Typhoid  Fever 238 

92.  Constipation  with  Mucous  Colitis 240 

93.  Trichiniasis 241 

94.  Ulcerative  Colitis 243 

95.  Amebic  Dysentery 244 

96.  Diarrhea  of  Unknown  Cause 245 

97.  Typhoid  Fever 246 

98.  Ulcerative  CoUtis 248 

CHAPTER   IV 

DYSPEPSIA 

General  Considerations 250 

What  is  Simple  Indigestion? 257 

Case  No. 

99.  Duodenal  Ulcer  with  Contracted  Scar 258 

100.  Chronic  Glomerular  Nephritis 261 

loi.  Cancer  of  the  Stomach , 265 

102.  Chronic  Glomerular  Nephritis 268 

103.  Hysteria  (Insanity?) 270 

104.  Cancer  of  the  Gall-bladder 272 

105.  Gall-stones 273 

106.  Brain  Tumor 275 

107.  Bad  Dietetic  Habits;  Constipation 277 

108.  Chronic  Glomerular  Nephritis 278 

109.  Hydronephrosis 279 

no.  Cancer  of  Vater's  Papilla 281 

111.  Pregnancy 283 

112.  Chronic  Plumbism  (?) 285 

113.  Kidney  Stones;  Left  Pyonephrosis 287 

114.  Bad  Dietetic  Habits 288 

115.  Cancer  of  the  Bile-ducts 290 

1x6.  Acute  Gastric  Indigestion 292 


lO  TABLE    OF    CONTENTS 

Case  No.  Pace 

117.  Meddlesome  Surgery;  Mysterious  Fever 294 

118.  Alcoholism 301 

119.  Social  jSIaladjustment;  Arteriosclerosis 302 

120.  Amyloid  Nephritis;  Ulcerative  Enterocolitis;  Purulent  Bronchitis 304 

121.  Phthisis. 306 

122.  Cirrhosis  of  the  Liver;  Sv^jhilis  (?) 308 

123.  Chlorosis;  Social  ^Maladjustment 310 

124.  Peptic  Ulcer 312 

125.  Gastric  Crisis  in  Tabes  Dorsalis 314 

126.  Gall-stones  in  the  Cystic  Duct;  Arteriosclerosis 316 

127.  Alcoholism;  Chronic  Peritonitis 318 

128.  Tabes  Dorsalis 321 

129.  Psychoneurosis 323 

130.  Phthisis 325 

131.  Acute  Indigestion  (from  overeating) 327 

132.  Cancer  of  the  Stomach 328 

133.  Phthisis 330 

134.  Pernicious  Anemia 333 

135.  ^Myeloid  Leukemia 334 

136.  Cancer  of  the  Cardiac  End  of  Stomach 336 

137.  Addison's  Disease 338 

138.  Gastric  Cancer;  Ovarian  Fibroma 341 

139.  Nervous  Dyspepsia;  Starvation 344 

140.  Adhesions  about  Gall-bladder  and  Colon;  Fibroid  of  Uterus 346 

141.  Gastric  Crises  of  Tabes  Dorsalis 348 

CHAPTER   V 

HEMATEMESIS 

Gener.\l  Considerations 35° 

Case  No. 

142.  Peptic  Ulcer;  Mitral  Stenosis 35° 

143.  Cancer  of  Stomach;  Ovarian  Fibromata 353 

144.  Cirrhotic  Liver;  Internal  Hydrocephalus;  Hemophilia 357 

145.  Cirrhosis  of  the  Liver 3^° 

146.  Menstrual  Vomiting 361 

147.  Tabes  Dorsahs;  Gastric  Crisis 361 

148.  Peptic  Ulcer 3^4 

149.  Splenic  Anemia 3^5 

CHAPTER  VI 

GLANDS 

General  Considerations 369 

Enlarged  Gl.ands  and  What  Simxh-ates  Them 369 

Clinical  Groupings 373 

Nomenclature  of  Gl.\ndul.ar  Tumors 374 

What  Other  Lumps   May  Be  Mistaken  for  Glands? 374 

Gland  Puncture 374 

Case  No. 

150.  Branchial  Cyst 375 

151.  Lymphoblastoma  (Hodgkin's  Disease) 37^ 

152.  Cancer  of  the  Thyroid 379 


TABLE    or    CONTENTS  II 

Case  No.  Page 

153.  Lymphoblastoma 380 

154.  Lymphoid  Leukemia. 381 

155.  Lymphoid  Leukemia 384 

156.  Syphilitic  Aortitis 386 

157.  Septic  Adenitis 388 

158.  Neuroblastoma  of  the  Neck,  etc 389 

159.  Tabes  Dorsalis;  Thyroid  Enlargement 391 

160.  Lymphoblastoma 393 

161.  Multiple  Myeloma 394 

162.  Acute  Lymphoid  Leukemia 396 

163.  Tuberculous  Adenitis  and  Tonsillitis 399 

164.  Tuberculous  Adenitis 401 

165.  Malignant  Lymphoma  (Lymphoblastoma) 402 

CHAPTER   VII 

BLOOD  IN  THE  STOOLS   (MELENA) 

General  Considerations 406 

Case  No. 

166.  Cancer  of  the  Rectum 408 

167.  TjT)hoid  Fever 410 

168.  Ulcerative  Colitis 411 

169.  Cancer  of  Stomach  with  Diffuse  Infiltration  and  Contraction 413 

1 70.  Bilharziasis 414 

171.  Amebic  Dysentery 415 

CHAPTER  VIII 

SWELLING  OF  THE  FACE 

General  Considerations 417 

Case  No. 

172.  Tertian  Malaria 419 

173.  Actinomycosis  of  the  Jaw 420 

174.  Mumps 421 

175.  Trichiniasis 422 

176.  Trichiniasis 424 

177.  Empyema  of  the  Antrum. 424 

1 78.  Erysipelas , 425 

179.  Edema  with  Erythema;  Vasomotor  Ataxia 426 

180.  Acute  Nephritis 427 

181.  Syphilitic  Laryngitis  with  Stenosis:  Deep  Cervical  Cellulitis  (Ludwig's  An- 

gina)    428 

182.  Chronic  Glomerular  Nephritis 430 

CHAPTER   IX 

HEMOPTYSIS 

General  Considerations 432 

Case  No. 

183.  Mitral  Stenosis;  Phthisis 434 

184.  Phthisis 438 

185.  Lobar  Pneumonia 440 

186.  Phthisis , 443 


12  TABLE   OF   CONTENTS 

Case  No.  Page 

187.  Congenital  Heart  Disease 445 

188.  Abscess  of  the  Lung;  Septicemia 447 

189.  Phthisis  (?) 451 

190.  Abscess  of  the  Lung 45  2 

191.  Hysteria  (?) 455 

192.  Incipient  Phthisis 460 

193.  Arteriosclerotic  Nephritis;  Pulmonary  Apoplexy 462 

194.  Arteriosclerosis;  Glomerular  Nephritis 463 

CHAPTER  X 

EDEMA  OF  THE  LEGS 

General  Considerations 465 

Local  Causes  of  Edema 465 

Varieties  and  Sites  of  Edema 466 

Edema  in  Convalescence 466 

Case  No. 

195.  Cirrhosis  of  the  Liver  (Syphilis?) 466 

196.  Phlebitis;  Arteriosclerosis 469 

197.  Flat-foot 470 

198.  Pernicious  Anemia 471 

199.  Trichiniasis 473 

200.  Endocarditis 475 

201.  Phlebitis;  Pulmonary  Infarct 477 

202.  Chronic  Glomerular  Nephritis 479 

203.  Syphilis;  Myocardial  Insufficiency;  Tabes;  Paralysis  of  the  Vocal  Cords.  .  481 

204.  Erythema  Multiforme 481 

205.  Alcoholic  Neuritis  with  Edema 482 

206.  Acute  Nephritis;  Cervical  Adenitis • 483 

207.  Alcoholic  Neuritis;  Myocardial  Weakness 484 

208.  Cirrhosis  of  Liver;  Arteriosclerosis;  Subacute  Glomerular  Nephritis 485 

209.  Arteriosclerosis;  Weak  Heart 487 

210.  Elephantiasis 488 

211.  Phthisis;  General  Miliary  Tuberculosis;  Tuberculous  Peritonitis 491 

212.  Acute  Glomerular  Nephritis 493 

CHAPTER   XI 
FREQUENT  MICTURITION  AND   POLYURIA 

General  Considerations 495 

Case  No. 

213.  Diverticulitis  Perforating  the  Bladder;  Syphilis 496 

214.  Cystitis;  Streptococcus  Infection 499 

215.  Anemia;  Debility 501 

216.  Pyelonephritis 502 

217.  Vesical  Calculus 504 

218.  Neurasthenia 505 

219.  Pyelonephritis 506 

220.  Tuberculous  Peritonitis ; 509 

221.  Tuberculosis  of  the  Kidney  and  Bladder '  510 

222.  Tuberculosis  of  the  Kidney  and  Bladder 512 

223.  Chronic  Glomerular  Nephritis;  Arteriosclerosis;  Myomalacia  Cordis 515 


TABLE    OF    CONTENTS  I 3 

Case  No.  Pack 

224.  Albuminuria  and  Glycosuria,  Cause  Unknown 518 

225.  Malignant  Disease  of  the  Ovary 519 

226.  Chronic  Nephritis  (Syphilitic?) 521 

227.  Colon  Bacillus  Infection  of  the  Urinary  Tract 522 

228.  Cystitis  (Tuberculous?) 524 

229.  Bilateral  Pyonephrosis;  Secondary  Anemia 525 

230.  Gonorrheal  Pyehtis;  Prostatitis;  Arthritis 528 

231.  Cancer  of  the  Bladder 529 

232.  Obstructing  Prostate;  Arteriosclerosis 530 

233.  Chronic  Interstitial  Nephritis 532 

234.  Diabetes  Insipidus;  Congenital  Syphilis 533 

235.  Diabetes  Mellitus 535 

236.  Diabetes  Mellitus;  Hemorrhoids;  Secondary  Anemia 536 

CHAPTER  XII 

FAINTING 

General  Considerations 541 

Case  No. 

237.  Chronic  Lead-poisoning 542 

238.  Hemorrhage  from  Duodenal  Ulcer 545 

239.  Chronic  Glomerular  Nephritis 546 

240.  Arteriosclerotic  Nephritis 548 

241.  Arteriosclerosis;  Cerebral  Hemorrhage 550 

242.  Arteriosclerosis;  Stokes-Adams  Disease 552 

243.  Pernicious  Anemia 553 

244.  Hysteria 555 

245.  Hysteria 557 

CHAPTER  XIII 

HOARSENESS 

General  Considerations 559 

Case  No. 

246.  Acute  Laryngitis;  Syphilis  (?) 560 

247.  Hysterical  Aphonia "... 562 

248.  Thoracic  Aneurysm 563 

249.  Papilloma  of  the  Larynx 566 

250.  Mediastinal  Neoplasm  (?) 567 

251.  Recurrent  Laryngeal  Paralysis;  Aneurysm  (?) 570 

252.  Aneurysm 571 

253-  SyphiUs  of  the  Larynx 573 

CHAPTER  XIV 

PALLOR 

General  Considerations S75 

Case  No. 

254.  Gastric  Cancer 575 

255.  Acute  Lymphoid  Leukemia 578 

256.  Chlorosis , . . .  580 


14  TABLE    OF    CONTENTS 

Case  No.  Page 

257.  Pernicious  Anemia 581 

258.  Subdiaphragmatic  Abscess  (Secondary  Anemia) 582 

259.  Pernicious  Anemia;  Arsenic-poisoning;  Arteriosclerotic  Nephritis 585 

260.  Chronic  Glomerular  Nephritis  (Streptococcus  Origin?) 588 

261.  Gastric.  Ulcer 590 

262.  Acute  Glomerular  Nephritis;  Syphilitic  Aortitis 592 

263.  Bothriocephalus  Latus 594 

CHAPTER    XV 

SWELLING   OF  THE  ARM 

General  Considerations 597 

Case  No. 

264.  Phlebitis 597 

265.  Osteomyelitis  of  the  Humerus 599 

266.  Phlebitis,  Cause  Unknown 600 

267.  Dilated  Aortic  Arch;  Phlebitis;  Edema  Due  to  Pressure 601 

268.  Tuberculous  Pericarditis  with  Effusion 603 

269.  Adherent  Pericardium;  Mitral  Stenosis 608 

270.  Pellagra 610 


CHAPTER  XVI 

DELIRIUM 

General  Considerations 612 

Case  No. 

271.  Typhoid  Fever 613 

272.  Postfebrile  Psychosis 615 

273.  Arteriosclerosis 616 

274.  Postfebrile  Psychosis 617 

275.  Exhaustion  Psychosis 619 

276.  Tertian  Malaria 621 

CHAPTER  XVII 
PALPITATION  AND   ARHYTHMIA 

General  Considerations 622 

Etiology 624 

Summary 624 

Case  No. 

277.  Myocardial  Weakness;  Hypertension 624 

278.  Neurosis 625 

279.  Paro.xysmal  Tachycardia 626 

280.  Dysthyroidism 628 

281.  Mitral  Stenosis 629 

282.  Pernicious  Anemia 630 

283.  Dysthyroidism 633 

284.  Cardiac  Neurosis  (Tobacco?) 634 

285.  Sinus  Arhythmia  (Cardiac  Neurosis) 635 

286.  Dysthyroidism 636 


TABLE    OF    CONTENTS  I 5 

CHAPTER  XVIII 

TREMOR  Page 

General  Considerations 639 

Case  No.  ' 

287.  Alcoholism 640 

288.  Paralysis  Agitans 642 

289.  Multiple  Neuritis  (?) ;  Syphilis 643 

290.  Hysteria 645 

291.  Multiple  Sclerosis 646 

CHAPTER   XIX 

ASCITES  AND  ABDOMINAL  ENLARGEMENT 

General.  Considerations 649 

Clinical  Statistics  of  Ascites 654 

Ascites  with  Solid  Tumors  of  the  Ovary 655 

Ascites  with  Cystic  Tumors  of  the  Ovary 655 

Ascites  with  Uterine  Fibromyoma 655 

Case  No. 

292.  Hepatic  Syphilis 656 

293.  Papillary  Cystadenoma  of  the  Ovary 657 

294.  Syphilis;  Syphilitic  Liver  (?) 658 

295.  Syphilitic  Nephritis 661 

296.  Chronic  Adhesive  Pericarditis 663 

297.  Cirrhosis  of  the  Liver 666 

298.  Cirrhosis  of  Liver  (Syphilitic?) 671 

299.  Tuberculous  Peritonitis  and  Salpingitis 674 

300.  Cirrhosis  of  the  Liver;  Thrombosed  Portal  Vein 676 

301.  Ovarian  Fibroma 677 

302.  Tuberculous  Peritonitis 678 

303.  Chronic  Glomerular  Nephritis 679 

304.  Cirrhosis  of  the  Liver 680 

305.  Pericardial  Adhesions 681 

306.  Ovarian  Cyst 682 

307.  SyphiUs 683 

308.  Neoplastic  Peritonitis  (Lymphoblastoma) ; 684 

309.  Chronic  Appendicitis  with  Abscess;  Pylephlebitis 685 

310.  SyphiUtic  (?)  Cirrhosis 687 

311.  Tuberculous  Peritonitis 689 

312.  Chronic  Glomerular  Nephritis;  Arteriosclerosis;  Myomalacia  Cordis  with 

Thrombi 690 

313.  Fibromyoma  of  the  Uterus 695 

314.  Gaseous  Distension 697 

315.  Ovarian  Cyst 698 

316.  Cancer  of  the  Liver 700 

317.  Obesity 703 


Index. 


70s 


DIFFERENTIAL  DIAGNOSIS 


CHAPTER   I 
ABDOMINAL  AND  OTHER  TUMORS 

The  diagnosis  of  abdominal  tumors  is  in  most  cases  either  easy 
or  impossible;  but  it  is  never  easy  unless  one  has  a  considerable 
knowledge  of  what  tumors  are  likely  to  occur  in  each  of  the  regions 
of  the  abdomen,  unless  one  has  taken  a  careful  history  and  made  the 
ordinary  manual  exploration  of  the  mass.  In  addition,  laboratory 
examinations  and  x-ray  exposures  are  sometimes  of  importance. 

Of  these  methods,  direct  palpation  of  the  tumor  may  be  the 
most  or  the  least  important  of  all.  Sometimes  it  tells  us  a  good 
deal,  but  usually  what  it  tells  us  is  interpreted  and  enlarged  very 
considerably  by  what  we  have  learned  to  expect.  For  example, 
an  epigastric  tumor  is  almost  always  cancer  of  the  stomach.  Should 
such  a  tumor  occur  in  a  child,  we  should,  of  course,  seek  some  other 
diagnosis;  but,  then,  such  a  tumor  very  rarely  does  occur  in  a  child. 

Certain  regions  of  the  abdomen  are  much  more  prone  to  contain 
tumors  than  others;  in  other  words,  the  diseases  which  produce 
tumor  in  the  abdomen  are  chiefly  those  of  the  pelvis  and  pelvic  or- 
gans, those  of  the  stomach,  liver,  and  kidneys.  Tumors  of  the  left 
hypochondrium  are  comparatively  rare,  and  almost  invariably  turn 
out  to  be  connected  with  the  spleen  or  left  kidney.  In  the  right 
hypochondrium  we  have  not  only  those  connected  with  the  liver  and 
gall-bladder,  but  those  connected  with  the  hepatic  flexure  of  the 
colon,  with  the  pyloric  end  of  the  stomach,  with  the  right  kidney, 
as  well  as  retroperitoneal  and  glandular  masses  which  often  push 
the  liver  forward  and  are  hidden  behind  it.  It  should  always  be 
remembered  that  a  doubtful  tumor,  seemingly  springing  from  the 
liver,  may,  in  fact,  be  a  normal  liver  pushed  downward  and  forward 
by  some  growth  behind  it.  Some  of  the  most  humiliating  mistakes 
that  I  have  known  have  been  due  to  forgetting  this  point. 

If  ascites  is  present,  our  diagnosis  is  much  simplified,  as  there 
are  comparatively  few  tumors  often  associated  with  ascites.     Such 

Vol.  II— 2  17 


Abdominal  Tumors 


PREGNANCY 

PASSIVE  CONGESTION  OF  THE  LIVER 

APPENDICITIS 

SPLENIC  TUMOR  IN  TYPHOID 

SALPINGITIS 

UTERINE  FIBROMYOMA  Bi^Hl 

OVARIAN    CYST  ^■■lEH 

HERNIA  ^KB^m 


CASES  TOO  MANY  AND  TOO 
MERABLE  FOR  GRAPHIC 
TION. 


ENLARGED    GALL-BLADDER  I 
IN   CHOLELITHIASIS  i 

NEOPLASM    OF  STOMACH 

SPLENIC     TUMOR     IN     MA- j 
LARIA,   ACUTE  STAGES        > 

CIRRHOTIC   LIVER 

SPLENIC    TUMOR     IN     CIR-| 
RHOSIS  OF   LIVER  • 

NEPHROPTOSIS 

TUBAL  PREGNANCY 

SOLID  TUMOR  OF  OVARY 

NEOPLASM   OF  INTESTINES 

NEOPLASM   OF   LIVER 

TUBERCULOUS   PERITONITIS 

CYST  OF   BROAD   LIGAMENT 


ABSCESS 
WALL 


OF     ABDOMINAL"! 


MALIGNANT  NEOPLASM  OF 
UTERUS 

HYPERTROPHY  OF 
SPLEEN-(UNKNOWN 
CAUSE) 

MALIGNANT  NEOPLASM  OF" 
KIDNEY 

MALIGNANT  NEOPLASM  OF' 
PANCREAS       AND       BILE- 
DUCTS 

ENLARGED    LIVER    IN    PER-" 
NICIOUS  ANEMIA 


VAGUELY  ENU- 
REPRESENTA- 


3519 
2515 
1539 
1282 
1099 


1095 

811 

753 

428 

428 

370 
348 
272 
224 
201 
163 
132 

131 
129 

121 

119 

119 

117 


Diagram  I. 


Abdominal  J vmoRS— continued 

TUMOROR  HYPERTROPHY 
OF       LIVER      (UNKNOWN  V     §■■  113 


CAUSE) 

ENLARGED    GALL-BLADDER 
IN  CHOLECYSTITIS 


SPLENIC   TUMOR    IN    PER- 
NICIOUS ANEMIA 

CARCINOMA       OF        GALL- 
BLADDER 

SPLENIC    TUMOR    IN     MY- 
ELOID  LEUKEMIA 

ENLARGED    LIVER    IN    MY- 
ELOID  LEUKEMIA 

ENLARGED  LIVER  IN 

CHRONIC  PERICARDITIS 


SPLENIC  TUMOR  IN  H0D6 
KIN'S  DISEASE 


RENAL     CALCULUS    (WITH 
HYDRONEPHROSIS) 


ENLARGED  LIVER  IN  HODG- 
KIN'S  DISEASE 


} 

STRUCTION  i 

} 


ENLARGED    LIVER   IN    LYM- 
PHOID LEUKEMIA 


MALIGNANT  NEOPLASM  0F\ 
ABDOMINAL  WALL  J 


1D| 
N-| 


KNOWN   CAUSE) 

} 
} 


ENLARGED  LIVER  IN  SUPPU 
RATIVE  PYLEPHLEBITIS 


SPLENIC   TUMOR    IN    LYM- 
PHOID LEUKEMIA 


105 


PYONEPHROSIS  1^  103 

TUBERCULOUS  KIDNEY  ^KM  101 

NEOPLASM  OF  PERITONEUM    ■■  95 


90 

88 
88 
84 
82 


HYDRONEPHROSIS  ■  73 

70 


67 


ABSCESS  OF  LIVER  ■  66 

ENLARGED  LIVER  IN  RICKETS   ■  63 


60 


PARANEPHRITIC  ABSCESS         ■  .  59 

ACUTE      INTESTINAL     OB- 


57 
51 
49 


HYPERTROPHY        AND" 
TUMOR    OF    OVARY   (UN-)-    ■  48 


48 


45 


INTUSSUSCEPTION  I  45 

Diagram  I — Continued. 

19 


20  DIFFERENTIAL  DIAGNOSIS 

are  cirrhosis  of  the  liver,  syphilis  of  the  liver  and  spleen,  tuberculous 
peritonitis  with  omental  or  glandular  masses  presenting  as  tumor, 
retroperitoneal  cancerous  metastases  from  neoplasm  of  the  stomach, 
gall-bladder,  or  pelvic  organs.  Lastly,  a  small  percentage  of  the 
cases  of  uterine  fibroid  and  ovarian  cyst  are  complicated  by  ascites. 
The  list  just  given  is  not  a  very  short  one,  but  it  has  this  character- 
istic, that  a  majority  of  its  members  can,  as  a  rule,  be  easily 
excluded  and  thus  a  diagnosis  of  the  cause  of  ascites  arrived  at. 

The  most  important  inquiries  in  relation  to  abdominal  tumors 
are  the  following: 

(i)  Duration  and  present  symptoms,  including  pain,  soreness, 
and  the  various  disturbances  of  function  (gastric,  intestinal,  biliary, 
urinary) . 

(2)  The  location  of  the  tumor,  with  especial  reference  to  its  con- 
nection with  one  or  another  abdominal  organ. 

(3)  Its  size,  shape,  and  consistency. 

(4)  Its  mobility  and  respiratory  mobility. 

(5)  The  determination  of  its  relation  to  the  stomach  and  colon: 
(a)  through  inflation  of  these  organs,  (b)  through  the  observation  or 
history  of  peristalsis  and  intestinal  noise. 

Aside  from  these  five  methods  of  examination  we  must  study: 

(a)  The  urine. 

{b)  The  blood,  especially  in  relation  to  the  Wassermann  reaction, 
the  presence  of  anemia,  leukemia,  or  leukocytosis.  Rarely  one 
must  also  search  for  the  complement  fixation  in  relation  to  hydatid 
disease  or  gonorrhea. 

(c)  The  stomach  contents. 

(d)  The  urine. 

(e)  The  x-ray  findings  after  a  bismuth  meal,  a  bismuth  enema, 
or  the  injection  of  a  silver  salt  to  the  pelvis  of  the  kidney. 

(/■)  The  temperature  chart. 

In  the  urine  the  most  important  points  are  the  presence  of  blood 
or  of  pus.     In  the  feces,  the  presence  of  blood,  pus,  or  parasitic  eggs, 

A  knowledge  of  the  relative  frequency  of  abdominal  tumors  is 
an  essential  part  of  their  diagnosis.  Some  guides  to  such  a  knowl- 
edge may  be  obtained  from  the  diagrams  which  follow.  (See  Dia- 
grams I,  II,  III,  IV,  V,  VI,  VII.)  Combining  the  knowledge  thus 
obtained  with  a  careful  history  of  the  case,  and  especially  with  the 
direct  and  indirect  evidence  touching  the  function  of  the  differ- 
ent abdominal  organs,  we  may  arrive  at  a  diagnosis  in  the  majority 
of  cases. 


Causes  of  Tumors  Involving  the  Abdominal  Wall 


HERNIA  ■^^■■■■^^^■■■■^^^■■^■i^  878 

ABSCESS                                   ■^^■^■■■■B  91 

MALIGNANT  NEOPLASM    ■§■■■  34 

ACTINOMYCOSIS                  ^  14 

HEMATOMA                            ■  11 

LIPOMA                                     ■  9 

FIBROMA                                  ■  5 

TUBERCULOSIS                     |  2 

Diagram  II. 


Tumors  of  the  Kidney 


NEPHROPTOSIS  Hi^H^H^^H^H^HH^^^^BIHHIIil^  370 

MALIGNANT  NEOPLASM  WK^^^^^^M  119 

PYONEPHROSIS  ■■^■■■■i  103 

TUBERCULOUS  KIDNEY  ^Hl^^^^  101 

HYDRONEPHROSIS  ^^HIHH  73 


CALCULUS  (WITH  HY- 
DRONEPHROSIS) 


PARANEPHRITIC      AB- 
SCESS 


67 


59 

CYST  ^  22 

Diagram  III. 


Tumors  of  the  Liver 


PASSIVE  CONGESTION  |  cases   too    many    and    too   vaguely    enumerable    for 
GALL-STONES  )      '^''"^"'"  REPRE^ntat.on. 

CIRRHOSIS  w^mmmmmt^K^^^i^a^m^mmmmm  428 

NEOPLASM  Bi^^^^HIH^^^Hi  201 

PERNICIOUS  ANEMIA  ^IH^^aBBB  117 

TUMOR    OF   HYP*JTRO-        

PHY     OF      LIVER     (UN- S-     Hl^^^^Bl  113 


KNOWN   CAUSE) 

MYELOID   LEUKEMIA  HHI^^^  84 

CHRONIC  PERICARDITIS  ■j^^l^  82 

ABSCESS  I^HB^  66 

RICKETS  ^I^HB  63 

LYMPHOBLASTOMA         1  ^^^^ 
(HODGKIN'S   DISEASE)/ 


SUPPURATIVE    PYLE- 
PHLEBITIS 


} 


CHOLANGITIS,  ACUTE  OR 
SUPPURATIVE 


48 


LYMPHOID   LEUKEMIA  ■■■  45 


31 


CATARRHAL  JAUNDICE            ■■  29 

CONGENITAL  SYPHILIS           ■■  26 

HYDATID  CYST                           ■§  18 

ACQUIRED  SYPHILIS        ,         ■(  17 

Diagram  IV. 


23 


Tumors  Involving  the  Uterus,  Ovaries,  or  Tubes 


(  CASES  TOO   MANY  AND  TOO   VAGUELY   ENUMERABLE   FOR   GRAPHIC   REPRE- 

PREGNANCY     < 

L      SENTATION. 


SALPINGITIS  l^l^^^HBHaHB^HHH^BI^^^HHB  2515 

UTERINE  FIBROMYOMA    ■■■{^^■■■■■I^^^^^H  1539 

OVARIAN   CYST  ^^H^^^^^^^^BIH  1282 

TUBAL   PREGNANCY  ^I^H^^HI  348 

SOLID       TUMOR       OF^ 
OVARY         (CANCER, 
109;  ADENOMA,  105; 
FIBROMA,    31  ;    PAP- 
ILLOMA,    15;      BAR-  I 
COMA,   12)  J 

CYST  OF  THE  BROAD  \     ^^     '  ^32 

LIGAMENT  * 


272 


MALIGNANT  NEO--^ 

PLASM  OF  UTERUS  1 
(CANCER,  124;  SAR-  | 
COMA,   5)  ^ 


129 


f 


HYPERTROPHY        OR 
UNSPECIFIEDrl  48 

TUMOR  OF  OVARY 


Diagram  V. 


24 


Causes  of  Tumors  Involving  the  Intestines  and 

Peritoneum 


f   CASES     TOO     MANY     AND    TOO     VAGUELY     ENUMERABLE     FOR     GRAPHIC 
APPENDICITIS  <  .,^.^,^., 

I        REPRESENTATION.  , 

NEOPLASM  OF  INTESTINES      HIHII^I^^^HHHHHHiHHaH^H  181 
TUBERCULOUS  PERITONITIS    ^■■■■^^^■■^^^^i^H^HI  146 

NEOPLASM  OF  PERITONEUM    Bi^^^^HHHHI^HH  84 


ACUTE      INTESTINAL     OB- 
STRUCTION 

ANEURYSM  OF  ABDOMINAL 
AORTA 


49 


35 


INTUSSUSCEPTION  Bi^^i^^  31 

30 


CHRONIC  INTESTINAL  OB 
STRUCTiONi 


NEOPLASM   OF  OMENTUM  ■■I^HI  21 

"FECAL  IMPACTION'"  I^HB  12 


NEOPLASM  OF  RETROPER- 
ITONEAL GLANDS 


DIVERTICULITIS  H^H  7 


^  Excluding  cases  known  to  be  of  neoplastic  origin. 

"  Cause    unknown;    some   organic    cause    (stricture,    tumor)    is    almost   invariably 
present. 

Diagram  VT. 


25 


Causes  of  Splenic  Tumor 


TYPHOID  3519 

MALARIA,   ACUTE  STAGES  753 

CIRRHOSIS  OF   LIVER  ^^^^■■^^■^■■■■■■■■H  426 

HYPERTROPHY,   UNKNOWN  |             ^^^^^^^^^^                                     ^^^ 

CAUSE  / 

PERNICIOUS  ANEMIA  ■■^^^^^■B                                               90 

MYELOGENOUS  LEUKEMIA  Hi^^^^^^                                               88 

HODGKIN'S   DISEASE  ^^^^^Bi^                                                   70 


BANTI'S   DISEASE  AND  SPLENIC 
ANEMIA 


ANEMIA      INFANTUM      PSEUDO- 
LEUK/EMICA 


} 


Diagram  VII. 


56 


LYMPHATIC   LEUKEMIA  ■^■^■■i  51 

CONGENITAL  SYPHILIS  WK^M  28 

ACQUIRED  SYPHILIS  ■■§  19 

POLYCYTHEMIA  ■§■  19 

CHRONIC   MALARIA  HI  13 

HEMOLYTIC  FAMILY  JAUNDICE        ■  7 

MALIGNANT   NEOPLASM  ■  7 

ABSCESS  I           •  4 

AMYLOID   DISEASE  |  3 

FLOATING  SPLEEN  I  2 


26 


ABDOMINAL   AND    OTHER   TUMORS  27 

Yet,  as  I  said  at  the  outset,  there  are  a  number  of  cases  which 
will  utterly  escape  us  despite  the  use  of  all  the  methods  and  pre- 
cautions above  suggested.  I  have  seen,  for  instance,  a  tumor  of  the 
tail  of  the  pancreas  which  could  not  by  any  possibility  have  been 
recognized  during  life.  Such  baffling  tumors  are,  fortunately,  not 
very  common,  but  they  will  occur  in  the  experience  of  every  one  who 
sees  many  patients.  Arnong  pelvic  tumors  diagnosis  is  frequently 
impossible,  partly  because  several  of  the  alternative  possibilities  may 
give  precisely  the  same  history,  the  same  data  on  palpation,  and  the 
same  laboratory  findings;  partly  also  because  these  supposed  alterna- 
tives may  all  be  present  at  once.  One  breaks  one's  heart  to  distin- 
guish a  fibroid  tumor  from  a  cystic  ovary,  or  a  salpingitis  from  an 
extra-uterine  pregnancy,  and  then  at  operation  finds  both  the  dis- 
eases present  at  once.  Such  mistakes  are  not  often  very  serious,  for 
what  we  have  chiefly  to  decide  is  whether  an  exploratory  operation 
is  necessary  or  not. 

Case  1 

A  waitress  of  twenty-seven  entered  the  hospital  March  29,  1909. 
The  patient  has  two  children,  the  youngest  four  years  old.  She  had 
a  miscarriage  two  years  ago,  and  was  operated  on  at  that  time;  she 
has  never  felt  well  since.  She  had  typhoid  in  the  Massachusetts 
General  Hospital  two  years  ago.  Her  menstruation  comes  every 
twenty-four  days.     The  last  period  was  three  weeks  ago. 

Three  days  ago  she  fell,  striking  the  right  side.  At  9  o'clock  last 
night,  without  warning  or  pain,  there  was  a  gush  of  bright  blood  from 
the  vagina.  She  went  to  bed  and  had  continuous  flowing  for  an 
hour  or  more,  with  slight  staining  since  then. 

Physical  examination  was  negative,  save  for  a  tumor  above  the 
pubes,  firm,  smooth,  rounded,  not  tender,  about  the  size  of  a  grape- 
fruit. There  were  no  masses  or  tenderness  in  either  culdesac,  but 
the  mass  described  was  easily  felt  and  was  apparently  continuous 
with  the  cervix.  It  was  freely  movable.  The  urine,  temperature, 
and  pulse  normal.  Dr.  Brewster  thought  the  patient  probably 
pregnant  and  advised  waiting  a  month.  She  left  the  hospital  April 
2d,  but  re-entered  April  15th,  having  been  at  the  Waverley  Con- 
valescent Home  until  the  day  before,  when  she  thought  she  felt  a 
lump  drop  down  in  her  abdomen.  She  also  said  she  felt  as  if  she  was 
"going  to  bust."  On  examination,  the  tumor  reached  from  just 
above  the  umbilicus  to  the  pubic  bone;  it  was  freely  movable 
from  side  to  side,  dull  on  percussion.      The  vagina  was  bluish,  the 


28  DIFFERENTIAL  DLAGNOSIS 

cervLX  soft  and  "taken  up."  There  was  no  demonstrable  milk  in 
the  breasts. 

Discussion. — With  no  cessation  of  menstruation,  one  naturally 
does  not  consider  pregnancy  in  this  case  until  other  and  more  obvious 
alternatives  have  been  ruled  out.  A  distended  bladder  is  the  first 
possibiUty  to  be  excluded.  Such  a  condition  is  not  common  in 
women  except  after  anesthesia  or  other  causes  of  coma.  In  the 
present  case  the  use  of  a  catheter  promptly  made  us  certain  that 
the  bladder  was  not  distended. 

Fibroid  tumors  are  not  common  in  women  of  this  age,  are  rarely 
so  smooth  and  symmetric,  and  are  often  well  recognized  by  the 
patient  herself  as  of  long  duration  before  it  seems  necessary  to  consult 
a  physician.  Fibroid  tumors  are  often  associated  with  metrorrhagia, 
such  as  was  present  in  this  case,  and  this  possibiUty  cannot  be  ruled 
out.  There  is  no  way  of  being  any  surer  as  to  diagnosis  unless  Ab- 
derhalden's  test  can  be  tried.  When  the  present  case  was  seen  Ab- 
derhalden's  work  had  not  been  published,  but  it  is  in  cases  such  as 
this  that  the  serum  diagnosis  of  pregnancy  is  most  valuable. 

Outcome. — On  the  20th  it  seemed  that  parts  of  the  fetus  could 
be  distinctly  felt,  and  being  assured  that  there  was  no  tumor,  but 
only  pregnancy,  the  patient  felt  better,  slept  well,  and  was  able  to 
leave  the  hospital  on  the  23d.  During  most  of  her  stay  the  tempera- 
ture ranged  between  99°  and  99^°  F.  In  due  time  she  gave  birth  to 
a  normal  child. 

Case  2 

A  Greek  of  twenty-seven,  employed  in  an  automobile  shop,  en- 
tered the  hospital  December  23,  1909.  The  patient  came  here  from 
Greece  seven  years  ago.  He  has  never  been  sick  until  the  present 
illness,  and  denies  the  use  of  alcohol.  About  a  month  ago  he  felt  a 
little  pain  in  the  region  of  the  liver  and  noticed  a  very  consider- 
able mass  in  that  region.  The  mass  has  steadily  increased  in  size 
ever  since,  and  for  two  weeks  he  has  had  enough  pain  there  to  disable 
him  from  work  and  disturb  his  sleep.     The  pain  is  worse  at  night. 

Physical  examination  shows  marked  bulging  of  the  lower  right 
ribs,  and  a  smooth,  firm  mass,  dull  on  percussion,  extending  from  the 
fourth  intercostal  space  in  the  nipple  line  to  the  umbilicus  and  as  far 
as  the  left  nipple  fine.  No  thrill  or  crepitus  is  felt  over  the  mass. 
There  is  no  edema.     Blood  and  urine  negative. 

Discussion. — The  essentials  of  this  case  are  as  follows:  A  mass, 
which  appears  to  be  an  enlarged  liver,  has  been  noticed  for  a  month 


ABDOMINAL  AND    OTHER   TUMORS  29 

by  a  young  Greek.  He  has  watched  it  grow  considerably  within 
that  time.  He  is  unusually  young  for  cancer  or  any  other  malignant 
disease  of  the  liver.  Moreover,  we  have  no  evidence  of  disease  in 
the  stomach  or  in  any  other  organ  whence  the  neoplasm  could  have 
been  carried  to  the  liver  by  metastasis. 

Syphilis  or  cirrhosis  of  the  liver  are  possible  diagnoses,  but 
neither  of  these  diseases  often  causes  as  much  pain  as  appears  to  have 
been  present  here.  There  is  no  reason  to  suppose  that  the  mass  is 
due  to  leukemic,  amyloid,  or  fatty  infiltration. 

If  these  diseases  are  excluded,  it  is  natural  to  consider  the  pos- 
sibility of  hydatid  disease,  especially  as  the  patient  is  Greek.  For 
the  association  of  Greeks  with  sheep  and  sheep  dogs,  in  their  own 
country,  is  well  known  to  be  a  potent  source  of  hydatid  disease. 
Nevertheless,  nothing  better  than  a  tentative  diagnosis  could  have 
been  made  in  this  case,  unless  additional  evidence  could  be  obtained 
by  testing  for  deviation  of  the  complement.  The.  absence  of  eosino- 
philia  is  notable. 

Outcome. — Operation,  January  6th,  showed  presenting  in  the 
wound  a  large  liver,  in  which  there  was  a  cyst  the  size  of  a  lemon. 
This  cyst  was  shelled  out  whole.  A  4-inch  incision  was  then  made 
in  the  anterior  surface  of  the  liver  and  another  large  cyst  with  a 
thick  white  wall  bulged  through  the  wound  and  ruptured,  with  the 
escape  of  a  large  quantity  of  yellow  fluid.  This  cyst  turned  out  to 
be  about  the  size  of  a  grape-fruit  and  was  removed  entire.  A  third 
cyst,  bulging  against  the  diaphragm  from  the  upper  surface  of  the 
right  lobe,  was  about  the  size  of  a  baseball.  This  cyst  was  ruptured 
into  the  cavity  of  the  larger  cyst  and  its  sac  was  removed  through 
the  original  liver  wound.  On  further  examination,  a  fourth  cyst, 
about  the  size  of  a  baseball,  was  felt  in  the  left  lobe  of  the  liver,  but 
was  not  removed.  The  fluid  removed  at  operation  from  the  cyst 
looked  like  serum,  but  contained  no  albumin.  The  patient  recov- 
ered fairly  well  from  the  operation,  but  developed  pneumonia  and 
died  January  14th.  The  autopsy,  January  i6th,  showed  echinococcus 
cyst  of  the  liver,  double  chronic  pneumonia,  and  purulent  bronchi- 
tis; fibropurulent  pleuritis  on  the  right,  obsolete  tuberculosis  of  the 
bronchial  lymphatic  glands,  enlargement  of  the  spleen,  and  chronic 
perisplenitis. 

Case  3 

A  housekeeper  of  fifty-seven  entered  the  hospital  January  21,  1908. 
Three  years  ago  the  patient  began  to  have  indigestion  and  simul- 


30 


DIFFERENTIAL  DIAGNOSIS 


taneously  uterine  flowing  at  very  irregular  intervals.  About  three 
months  ago  she  noticed  that  her  lower  abdomen  was  hard.  For 
many  years  she  has  had  varicose  veins  in  the  right  leg  and  for  ten 
years  has  worn  an  elastic  stocking.  A  week  ago  she  woke  up  in  the 
night  with  severe  pain  in  the  right  leg.  This  pain  has  continued 
since  and  has  disturbed  sleep.  For  three  days  it  has  confined  her  to 
bed. 

Physical  examination  was  essentially  negative  except  as  related 
to  the  abdomen,  in  the  lower  part  of  which  was  a  large,  nodular, 
tender,  rounded  mass,  extending  from  the  pubic  bone  to  a  point 

3  inches  above  the  umbilicus, 
and  from  the  right  flank  to  a 
point  4  inches  to  the  left  of 
the  median  Hne.  It  was  dull 
on  percussion  and  sHghtly  mov- 
able. The  rest  of  the  abdomen 
was  negative.  On  the  inner 
surface  of  the  right  lower  leg 
was  an  area  of  redness  and 
swelling,  extending  from  the 
shin  around  to  and  past  the 
median  line  behind,  and  from 
the  ankle  nearly  to  the  knee. 
On  the  inner  portion  of  this 
were  several  large  blue  veins; 
within  the  area  firm,  venous 
trunks  could  be  felt  and  could 
be  traced  from  there  up  past  the 
knee,  on  the  inner  side.  The 
urine  was  negative.  The  blood 
showed  a  leukocytosis  varying  from  20,000  at  entrance  to  .36,000  on 
the  5  th  of  February  and  accompanying  a  sHght  febrile  reaction 
(Fig.  i).  After  that  it  gradually  declined,  although  on  the  12th  of 
March  it  was  still  19,000.  On  the  21st  of  March  it  was  10,000.  On 
the  23d  a  vein,  large,  firm,  and  sHghtly  tender,  could  be  traced  from 
the  left  knee  to  the  groin.  There  was  a  good  deal  of  edema  of  the 
leg  and  thigh.  This  increased  up  to  the  first  week  in  February,  then 
began  to  go  down.  The  thigh  measured  24  inches  as  against  17  on 
the  other  side.  On  the  21st  of  February  the  patient  was  delirious 
and  disorientated,  with  marked  weakness  and  a  poor  pulse.  On  the 
23d  free  fluid  was  demonstrable  in  the  abdomen.     On  the  8th  of 


r;^ ,— — it 

1  lU  i  f  i'  U  1  S-  fo 

1»T"--    \\\   T  •    •/+    7-='  / 

II  \7    ■    ::l  II  1    /-  ill  II 

101 

. 

«     IM- 

- 

1  r^^^^/^/**^^: 

^g.-'i'^-^-^^- 

, 

-            ^tz 

. 

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a 

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s-  "  „^t^^^^'*^\l 

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1  "   1  1  1  1  M  1  1  M 

jl 

Fig.  I. — Chart  of  Case  3. 


ABDOMINAL  AND    OTHER   TUMORS  3 1 

March  there  was  slight  divergent  strabismus  and  extensive  edema 
of  the  skin  of  the  back,  extending  up  to  the  midscapular  region,  and 
associated  with  dulness  and  rales  at  the  bases  of  the  lungs.  On  the 
29th  of  March  the  eyes  were  a  little  puffy  in  the  morning.  Meantime 
the  patient  had  steadily  emaciated.  The  superficial  veins  over  the 
abdomen  were  beginning  to  enlarge. 

Discussion. — Fibroid  of  the  uterus,  complicated  by  a  phlebitis 
of  the  leg,  is  naturally  the  first  thing  to  consider  in  this  case.  The 
leukocytosis  is  naturally  to  be  explained  as  a  result  of  the  phlebitis. 

Later  on  in  the  course  of  the  case,  however,  when  ascites  was 
demonstrated,  mental  symptoms  appeared,  and  the  edema  extended 
up  the  thorax,  it  became  clear  that  the  inferior  cava  must  have  be- 
come blocked.  This  accident  is  very  rarely  associated  with  fibroid 
of  the  uterus.  •  The  rarity  of  this  combination  and  the  steady  emacia- 
tion of  the  patient  might  have  led  us  to  change  our  diagnosis.  Never- 
theless, up  to  the  time  of  death,  no  such  change  was  made,  and  the 
case  was  beheved  to  be  one  of  uterine  fibroid  with  complicating 
phlebitis. 

Outcome. — The  patient  showed  but  little  change  except  for  gradual 
failure,  and  on  the  23d  of  May  she  quietly  died.  Autopsy  showed 
multilocular  adenocystoma  of  the  right  ovary.  Thrombosis  of  the 
inferior  vena  cava,  of  the  iliac  veins,  and  their  tributaries;  sHght 
chronic  interstitial  nephritis;  senile  degeneration  of  the  myocardium; 
small  myomata  of  the  uterus;  ascites;  double  hydrothorax. 

Case  4 

A  hardware  merchant  of  thirty-four  entered  the  hospital  March 
15,  1908.  The  patient's  mother  died  at  forty-six  of  apoplexy,  one 
sister  of  Bright's  disease,  otherwise  the  family  history  is  negative. 
His  own  health  and  habits  have  been  excellent. 

Six  months  ago  he  began  to  have  a  cough  with  considerable  sputa 
and  pain  in  the  arms  and  legs.  At  the  same  time  he  noticed  enlarge- 
ment of  the  abdomen.  It  felt  "a  little  crowded."  These  symptoms 
have  continued  without  much  change,  but  have  not  prevented  him 
from  working  in  his  store  until  three  and  a  half  weeks  ago,  when  the 
cough  ceased  and  he  noticed  in  the  left  side  of  his  abdomen  a  bunch 
as  large  as  a  croquet  ball  and  tender,  especially  when  he  coughed. 
He  went  to  bed  at  his  doctor's  suggestion  and  the  tumor  and  tender- 
ness disappeared.  Two  weeks  ago  he  was  again  up,  but  felt  worn  out. 
Six  days  ago  a  second  bunch  appeared  in  his  right  side,  about  as 
large  as  the  first,  but  more  tender.     From  this  time  the  abdomen 


32 


DIFFERENTIAL   DL\GNOSIS 


has  steadily  enlarged.  He  has  noticed  no  change  in  color,  but  his 
bowels  have  been  loose  for  six  months,  moving,  as  a  rule,  four  times 
a  day.  Four  or  five  weeks  ago  he  had  a  nosebleed.  Two  weeks  ago 
the  abdomen  was  tapped,  but  no  fluid  obtained.  Yesterday  morn- 
ning  he  began  to  notice  that  the  light  hurt  his  right  eye,  which  felt 
as  if  it  were  bulging  out. 

Physical  examination  shows  fair  nutrition,  mucous  membranes 
pale.     The  right  eye  protrudes  farther  than  the  left,  and  its  move- 


Fig.  2. — Physical  signs  in  Case  4. 

ments  are  markedly  limited  in  all  directions.  The  pupils  are  normal. 
There  is  systolic  pulsation  in  the  suprasternal  notch.  The  heart's 
impulse  is  seen  and  felt  in  the  fifth  space,  2|  inches  outside  the  nipple 
hne;  right  border  i|  inches  to  the  right  of  midsternum.  In  the  third 
left  space,  near  the  sternum,  systolic  pulsation  is  visible  and  palpable. 
Substernal  dulness  2^  inches  wide  at  the  second  interspace.  No 
murmurs.  First  apex-sound  forcible.  Blood-pressure  125  mm.  Hg. 
Lungs  negative  save  for  dulness  at  the  bases,  especially  the  right,  and 


ABDOMINAL  AND    OTHER  TUMORS 


33 


occasional  moist  rales.  The  abdomen  is  prominent,  navel  flushed, 
and  the  veins  well  marked.  It  is  flat  on  percussion  and  everywhere 
resistant, .  except  for  small  af eas  of  tympany  and  softness  in  the 
flanks  (Figs.  2  and  3).  In  the  right  lower  quadrant  there  is  a  very 
tender,  rounded  prominence,  rising  above  the  hard,  smooth  surface 
of  the  surrounding  parts.  A  somewhat  similar  enlargement  is  noticed 
in  the  left  upper  quadrant.  The  whole  mass  moves  very  sHghtly 
with  respiration.  The  liver  edge  is  not  felt,  there  is  no  edema,  no 
glandular  enlargement.     Reflexes  normal. 


Fig.  3. — Chest  signs  in  Case  4. 


Discussion. — A  bunch  in  the  left  upper  quadrant  usually  repre- 
sents some  disease  of  the  spleen  or  kidney.  Organic  disease  of  the 
stomach  or  pancreas  very  seldom  gives  us  a  tumor  in  this  vicinity, 
though  gastric  flatulence  is  a  frequent  cause  of  pain  in  this  spot. 
Occasionally  we  have  pain  and  tumor  in  this  region  from  cancer  of 
the  splenic  flexure  of  the  colon.  The  association  of  tumor  with  diar- 
rhea in  this  case  makes  the  possibility  of  intestinal  cancer  more 
considerable,  since  it  must  never  be  forgotten  that  the  intestinal 
cancer  produces  diarrhea  as  often  as  it  does  constipation. 

Vol.  II— 3 


34  DIFFERENTIAL  DIAGNOSIS 

With  the  appearance  of  the  second  bunch  on  the  other  side  of  the 
abdomen  and  also  of  a  source  of  pressure  behind  the  right  eyeball, 
we  are  forced  to  suppose  that  more  than  one  focus  for  •  disease  is 
present  and,  therefore,  that  cancer  of  the  intestine  is  improbable. 
If  the  mass  were  a  hypernephroma,  these  second  bunches  might  repre- 
sent metastases;  or,  if  the  blood  turned  out  to  be  normal,  a  mahgnant 
lymphoma  would  be  a  possibility.  Indeed,  the  symptoms  and  tumor 
masses  are  strikingly  similar  to  those  that  I  have  seen  in  some  cases 
that  turned  out  to  be  malignant  lymphoma.  Everything  must  rest, 
in  such  a  case,  upon  the  results  of  blood  examination. 

Outcome. — The  blood  showed  2,680,000  red  cells;  hemoglobin, 
70  per  cent. ;  white  cells,  290,000.  Differential  count  showed :  poly- 
nuclears,  51  per  cent.;  myelocytes,  42  per  cent.;  lymphocytes,  2  per 
cent.;  eosinophiles,  2.5  per  cent.;  mast  cells,  2.5  per  cent.  The  urine 
showed  a  slight  trace  of  albumin  with  many  fine  and  coarse  granular 
casts,  otherwise  negative.  Treatments  by  x-ray  were  begun  at  once 
and  by  the  i8th  the  eye  had  returned  to  its  normal  position  and  moved 
freely.  The  fundus  oculi  showed  a  few  small  hemorrhages  in  the 
right  retina,  more  on  the  left.  By  the  4th  of  April  the  patient  was 
free  from  pain  and  showed  very  great  subjective  improvement.  The 
blood,  however,  had  not  essentially  changed.  He  left  the  hospital 
that  day. 

Postscript. — A  rare  feature  of  this  case  is  the  association  of  mul- 
tiple glandular  tumors  (for  apparently  that  is  what  we  are  dealing 
with)  with  a  blood-picture  ordinarily  associated  with  the  myelogenous 
(not  with  the  glandular)  form  of  leukemia.  Ordinarily  the  bone- 
marrow — not  the  lymph-glands — is  the  seat  of  the  trouble  in  cases 
showing  such  a  blood-picture  as  this. 

Case  5 

A  German  housewife  of  forty-six  entered  the  hospital  August  22, 
1908.  The  patient's  family  history  and  past  history  are  negative. 
She  passed  the  menopause  three  months  ago.  Eighteen  months  ago 
she  began  to  have  headache  and  vomiting  in  attacks  lasting  from  a 
few  hours  to  a  few  days  and  increasing  in  frequency.  The  vomiting 
came  usually  after  rtieals  and  consisted  of  food.  No  blood;  no  pre- 
ceding nausea.  The  appetite  has  remained  good.  The  headache 
came  always  on  the  top  of  the  head  and  has  recently  needed  morphin 
for  relief.  She  had  lost  much  in  weight  and  strength.  She  occa- 
sionally felt  backache  and  a  dull  ache  in  the  right  side  of  the  abdomen. 


ABDOMINAL   AND    OTHER   TUMORS 


35 

No 


In  the  evenings  she  had  noticed  a  slight  swelling  of  the  ankles, 
nocturia. 

Physical  examination  (including  the  urine  and  blood-pressure)  is 
negative,  save  for  the  abdomen.  Just  inside  the  right  anterior 
superior  spine  of  the  ileum  is  a  fairly  soft,  tender,  movable  mass, 
about  7  cm.  in  diameter.  Near  this  mass  the  right  kidney  can  also 
be  felt,  but  the  two  are  separate.  Dr.  C.  A.  Porter  made  diagnosis 
of  cancer  of  the  cecum  (Fig.  4). 


Fig.  4. — Physical  signs  in  Case  5. 

The  lower  mass  ultimately  proved  to  be  a  displaced  kidney.     The  upper  mass  was  not  a 

kidney  as  we  thought,  but  a  "corset  lobe"  of  the  liver. 

Discussion. — The  headache,  loss  of  weight,  vomiting,  and  edema 
make  us  think  of  nephritis  first  of  all,  but  the  negative  urine  and 
normal  blood-pressure  exclude  this.  Our  attention,  then,  is  concen- 
trated upon  the  mass  or  masses  felt  in  the  right  upper  quadrant. 
Against  the  diagnosis  of  cancer  of  the  cecum  is  the  fact  that  there 
have  been  no  symptoms  referable  to  the  intestine,  no  marked  consti- 
pation, no  pain  locahzed  at  the  cecum,  no  intestinal  noise  or  \dsible 
peristalsis,  and,  so  far  as  we  know,  no  blood  in  the  stools.     It  must 


36  DIFFERENTLA.L  DLA.GNOSIS 

be  remembered,  however,  that  cancer  of  the  cecum  is  sometimes 
an  extraordinarily  latent  disease,  covering  considerable  periods 
of  time.  Several  patients  whom  I  have  studied  and  in  whom  cancer 
of  the  cecum  has  been  proved  by  operation,  have  assured  me  that 
the  lump  which  I  felt  prior  to  the  operation  had  been  there  for  sev- 
eral years  without  producing  any  other  symptoms.  I  have  myself 
studied  such  a  lump,  discovered  by  a  patient,  utterly  symptomless, 
and  finally  proved  to  be  cancer  after  I  had  watched  it  (the  patient 
refusing  operation)  throughout  nearly  a  year's  time.  Further  evi- 
dence on  this  question  of  cecal  cancer  might  be  obtained  by  bismuth 
rr-ray  examination,  which  in  1908  we  were  not  carrying  out;  also  by 
repeated  tests  of  the  feces  for  occult  blood.  Malignant  lymphoma 
of  the  small  intestine  (ordinarily  called  sarcoma)  cannot,  so  far  as  I 
see,  be  positively  excluded.  Such  tumors,  in  my  experience,  are 
much  more  movable  than  was  the  tumor  present  in  this  case.  They 
are  often  multiple  and  usually  give  rise  to  some  intestinal  symptoms, 
the  absence  of  which  in  this  case  has  already  been  mentioned. 

Can  this  mass  be  connected  with  the  liver?  It  seems  decidedly 
too  far  to  the  right  to  be  a  distended  gall-bladder,  unless  we  assume 
that  in  some  mysterious  way  a  gall-bladder  is  dislocated  far  from 
its  normal  position. 

Malignant  disease  involving  the  liver  usually  produces  an  en- 
largement of  the  whole  organ  and  shows  multiple  nodules,  provided 
that  it  is  accessible  to  physcial  examination  at  all.  A  single  circum- 
scribed mass,  like  that  here  represented,  is  not  at  all  common  in 
hepatic  neoplasms. 

Syphilis  of  the  liver  might  produce  such  a  tumor.  One  would 
expect,  however,  if  syphilis  were  present,  to  feel  other  lobules  or 
masses,  the  result  of  scarring  of  the  liver  substance  by  gummata. 
Further  evidence  might  be  obtained  by  a  Wassermann  reaction. 

Tumors  of  the  omentum  (which  are  usually  metastatic)  are 
among  the  most  freely  movable  of  all  the  abdominal  tumors,  and 
are  seldom  if  ever  found  fixed  near  the  spine  of  the  ileum. 

If  we  assume  that  the  physical  examination  is  correct  and  that 
the  right  kidney  is  entirely  separate  from  the  tumor  mass,  we  can- 
not further  discuss  an  involvement  of  the  kidney  itself.  It  might 
well  be,  however,  that  we  were  mistaken  in  believing  that  the  kidney 
could  be  clearly  differentiated  from  the  tumor.  In  that  case,  hydro- 
nephrosis, cystic  kidney,  renal  tuberculosis,  and  hypernephroma 
would  all  need  to  be  considered.  There  is  nothing  in  the  urine  to 
indicate  any  renal  disease  and  nothing  in  the  history  to  indicate 


ABDOMINAL  AND    OTHER   TUMORS  37 

tuberculous  infection  or  neoplastic  cachexia.  If  cystic  kidney  were 
present,  we  should  usually  be  able  to  feel  a  similar  mass  upon  the 
other  side,  since  this  disease  is  almost  invariably  bilateral  and  con- 
genital. The  question  of  hydronephrosis  might  be  settled  by  taking 
an  x-ray  plate  after  the  injection  of  collargol  into  the  renal  pelvis . 

Outcome. — On  the  3d  of  September  the  abdomen  was  opened. 
The  cecum  was  found  normal,  but  behind  it  was  a  mass  which  seemed 
to  be  a  low-placed  kidney.  A  lobe  of  the  liver  projected  downward 
like  a  tongue,  assuming  the  shape  and  position  of  the  normal 
kidney  (Fig.  4).  The  stomach,  pylorus,  duodenum,  gall-bladder 
and  ducts,  the  pelvic  organs,  the  intestines,  and  the  left  kidney  were 
examined  and  found  normal.  The  posterior  wall  of  the  peritoneum 
was  then  opened  and  the  right  kidney  exposed.  The  kidney  was 
found  to  be  large,  irregular  in  shape,  and  the  vessels  and  ureter  placed 
high  in  the  anterior  wall.  A  partial  nephropexy  was  done.  The 
patient  recovered  well  from  the  operation,  but  a  few  days  later  nausea 
returned.  On  the  9th  of  September  a  peristaltic  wave  was  seen 
sweeping  across  the  middle  of  the  abdomen,  where  it  appeared  that 
a  large  coil  of  intestine  was  pushed  forward  and  fixed.  In  Dr.  Cod- 
man's  opinion  this  was  the  duodenum.  Washing  out  the  stomach 
gave  some  relief.  The  patient  was  advised  to  lie  continuously  on 
the  right  side  and  on  the  abdomen.  A  good  deal  of  relief  resulted 
from  this,  and  by  the  13th  the  patient  was  taking  liquids  well  by 
mouth  and  steadily  gaining.  On  the  26th  of  September  she  left  the 
hospital  apparently  well.  October  7,  1909,  the  patient  reported  at 
the  accident  room  in  perfect  condition.  The  diagnosis  stands  as 
congenitally  deformed  kidney,  gastromesenteric  ileus.  The  upper 
mass,  supposed  to  be  the  kidney,  was  apparently  a  "corset  lobe"  of 
the  liver,  while  the  lower  mass  was  the  kidney  itself. 

Case  6 

A  housewife  of  seventy  entered  the  hospital  August  28,  1908. 
The  patient's  mother  and  one  brother  died  of  consumption ;  otherwise 
the  family  history  and  past  history  are  good.  For  the  past  year  she 
has  had  some  general  abdominal  pain,  not  severe  or  localized,  not 
preventing  work  or  sleep.  Appetite  fair;  bowels  very  costive.  She 
had  several  short  attacks  of  vomiting  and  has  lost  much  in  weight  and 
strength. 

Six  days  ago  she  began  to  have  severe  pain  in  the  right  side  of 
the  abdomen,  but  has  remained  up  and  about  until  today,  and  has  not 
vomited.     Food  does  not  seem  to  influence  the  pain. 


38 


DIFFERENTIAL  DIAGNOSIS 


Physical  examination  shows  poor  nutrition  and  pallor.  Above 
the  middle  of  the  left  clavicle  is  a  small,  hard,  round,  pulsating  tumor, 
3  cm.  in  diameter.  (The  patient  had  never  noticed  it.)  The  heart's 
impulse  extends  13  cm.  to  the  left  of  midsternum,  2  cm.  outside  the 
midclavicular  line.  There  is  no  enlargement  to  the  right.  The 
action  is  somewhat  irregular.  A  rough  systolic  murmur  is  heard  at 
the  apex  and  in  the  axilla.  The  systoHc  blood-pressure  is  160  mm.  Hg. 
Lungs  negative.  Filling  the  right  upper  quadrant  of  the  abdomen 
and  extending  below  the  umbihcus  is  a  hard,  tender,  irregular  mass, 


Fig.  5. — Physical  signs  in  Case  6. 


palpable  bimanually,  not  descending  with  inspiration  (Fig.  5). 
Otherwise  the  abdomen  is  negative.  There  is  a  slight  edema  of  the 
lower  legs.  Blood  and  urine  normal.  No  fever  in  a  week's  observa- 
tion. 

Discussion. — The  history  gives  us  no  clue  at  all.  We  know  that 
the  patient  has  lost  weight,  but  at  her  age  this  helps  us  very  little. 
The  pulsating  tumor  above  the  clavicle  should  suggest,  to  anyone 
who  has  ever  seen  a  similar  case,  that  we  are  deahng  with  a  displaced 
subclavian  artery  crossing  a  cervical  rib.     This  is  practically  the 


ABDOMINAL  AND   OTHER  TUMORS  39 

only  common  cause  of  pulsating  tumors  in  the  neck.  Aneurysms 
very  seldom  present  at  this  point,  that  is,  in  or  outside  the  mid- 
clavicular line.  They  are  almost  always  in  the  vicinity  of  the  supra- 
sternal notch,  when  they  extend  above  the  thoracic  cavity. 

A  soft  pulsating  neoplasm,  probably  metastatic,  deserves  merely 
to  be  mentioned.  Such  a  tumor  is  very  rare.  The  diagnosis  between 
this  and  a  misplaced  subclavian  artery  can  easily  be  made  by  a:-ray 
examination. 

Beyond  this  we.  have  to  deal  with  the  tumor  in  the  right  upper 
quadrant  and  flank.  From  a  diagnostic  point  of  view,  the  most 
important  facts  about  this  tumor  is  that  it  does  not  descend  with 
inspiration  and  that  we  have  no  evidence  of  its  connection  with  the 
liver.  Its  size  and  position  correspond  much  more  nearly  with  a 
tumor  connected  with  the  kidney  than  with  any  other  growth.  To 
determine  this  point  more  accurately,  the  colon  should  be  inflated. 
If  the  inflated  colon  comes  in  front  of  the  tumor,  the  latter  is,  in 
all  probability,  connected  with  the  kidney.  On  statistical  grounds 
we  should  assume  that  if  it  is  a  renal  tumor,  it  is  probably  a  hyper- 
nephroma. 

The  patient,  no  doubt,  has  some  arteriosclerosis,  both  in  and 
beyond  the  renal  vessels.  The  heart  is  doubtless  hyper trophied 
and  dilated  and  its  walls  weakened.  There  is  no  reason  to  beheve 
that  any  valvular  lesion  exists.  Murmurs  like  those  here  described 
are  very  common  in  hearts  which  turn  out  at  autopsy  to  be  quite  free 
from  any  valvular  lesion. 

Outcome. — The  inflated  colon  traversed  the  tumor;  x-ray  showed 
bilateral  cervical  ribs.  The  left  subclavian  artery  traversed  one  of 
these.  Operation  (for  possible  hypernephroma)  was  refused,  and  the 
patient  left  the  hospital  on  the  2d  of  September. 

Case  7 

A  housekeeper  of  forty-five  entered  the  hospital  September  16, 
1908.  Two  years  before  entrance  the  patient  noticed  prominence 
in  the  region  of  each  collar-bone,  and  for  one  year  has  thought  that 
the  right  side  of  the  face  was  swollen.  She  has  had  indigestion  for  a 
long  time  when  she  is  careless  as  to  diet.  If  she  is  careful  she  has 
no  trouble.  Three  months  ago  she  began  to  lose  weight  and  strength. 
Her  usual  weight  being  144  pounds,  she  has  fallen  within  a  short  time 
to  132  pounds.  She  has  a  desire  to  regurgitate  food  after  a  good  many 
meals.  Her  family  history  is  negative,  Hkewise  her  past  history,  ex- 
cept for  an  attack  of  sharp  pain  in  the  right  hypochondrium  eighteen 


40 


DIFFERENTIAL  DLA.GNOSIS 


S>j^ 


years  ago.     This  was  called  "inflammation  of  the  liver,"  was  not 
accompanied  by  jaundice,  and  passed  off  within  a  few  days. 

Physical  examination  shows  poor  nutrition,  sHght  pallor,  pupils, 
glands,  and  reflexes  normal.  In  the  region  of  the  right  temple  is  a 
slight  prominence,  hard,  not  tender,  apparently  connected  with  the 
bone.  The  left  clavicle  is  prominent  and  apparently  thickened 
throughout.  Scattered  over  the  face  there  are  numerous  areas  of 
erythema,  2  mm.  in  diameter.  There  are  a  few  larger  areas  on  the 
chin  covered  with  fine,  white  scales.  The  heart  is  negative  save  for  a 
soft,  systolic  murmur  at  the  apex,  not  transmitted.  The  left  pulse 
is  sHghtly  greater  than  the  right;  otherwise  both  are  negative.  The 
lungs  are  normal.  The  edge  of  the  liver  can 
be  felt  below  the  ribs,  and  in  the  epigastrium 
there  is  an  indefinite  resistance.  The  upper 
border  of  liver  dulness  is  at  the  sixth  rib. 
The  edge  of  the  spleen  is  felt  4  cm.  below 
the  ribs.  There  are  dilated  veins  on  both 
legs  and  slight  soft  edema  of  the  ankles. 
The  tibise  seem  rather  rough  and  irregular. 
Systolic  blood-pressure,  115  mm.  Hg.  Blood 
and  urine  negative.  Slight  irregular  fever  as 
shown  in  the  accompanying  chart  (Fig.  6). 
Tube-examination  showed  apparently  a  small 
amount  of  food  in  the  fasting  stomach.  On 
inflation,  its  upper  border  was  at  the  ensiform; 
the  lower  border  4^  cm.  below  the  navel. 
No  additional  information  about  the  abdo- 
men was  obtained  through  this  inflation. 
Microscopic  examination  of  the  fasting  con- 
tents showed  that  what  had  been  taken  for 
food  was  not  such,  mucus  and  epithehal  cells  making  up  the  whole 
residue.  Guaiac  test  was  negative  and  free  HCl  present.  After  a 
test-meal  the  stomach  contents  showed  free  HCl,  but  too  small  an 
amount  to  be  tested  quantitatively. 

Discussion. — Prominence  of  the  collar-bones  and  of  one  temple, 
associated  with  loss  of  weight,  are  apparently  the  essential  data  in 
this  case.  There  are  also  facts  suggesting  enlargement  of  the  spleen 
and  liver,  and  possibly  some  syphilitic  or  other  type  of  periostitis 
on  the  shin  bone.  The  history  of  fever  and  the  negative  results  of 
stomach  examination  are  also  of  importance. 

So  slow  an  enlargement  of  both  collar-bones  is  not  likely  to  be 


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Fig.  6. — Chart  of  Case  7, 


ABDOMINAL  AND    OTHER  TUMORS  4 1 

due  to  syphilis.  Syphilitic  lesions  of  the  collar-bone  are  generally 
unilateral  and  circumscribed.  They  are  apt  to  be  associated  either 
with  tenderness  or  areas  of  softening,  such  as  were  absent  in  this 
case. 

Metastatic  neoplasms  dependent  upon  hypernephroma  or  some 
other  distant  focus  are  very  rarely  bilateral  or  symmetric.  More- 
over, we  have  nothing  to  suggest  the  presence  of  any  primary  focus 
of  maUgnant  disease. 

Rachitis  and  other  congenital  malformations  can  be  excluded 
only  by  x-ray  examination.  Everything  in  the  case  points  to  this 
method  of  examination  as  the  most  important  step  next  to  be  taken. 
The  x-ray  should  include  the  tibiae,  as  well  as  the  collar-bones.  I  may 
add  that  the  findings  shown  in  the  outcome,  presently  to  be  men- 
tioned, were  wliolly  unexpected  to  me  and,  I  think,  to  all  who  saw 
the  case. 

Outcome. — After  the  time  of  entrance  the  edge  of  the  liver  was 
never  felt  again,  though  the  spleen  could  always  be  felt;  x-ray  plates 
were  taken  of  the  whole  bony  skeleton,  and  no  changes  found  except 
in  the  clavicles,  which  showed  lesions  of  osteitis  deformans  in  the 
opinion  of  Drs.  Dodd  and  of  E.  A.  Locke,  whose  experience  with 
this  disease  is  more  extensive  than  that  of  any  living  observer.  The 
patient  left  the  hospital  September  26th,  considerably  relieved, 
having  gained  3I  pounds. 

Case  8 

A  housekeeper  of  fifty  entered  the  hospital  October  15,  1908. 
For  three  months  the  patient  has  had  severe  headaches,  constipation, 
and  loss  of  appetite.  For  a  week  she  has  had  pain  in  the  left  lower 
quadrant,  never  sharp,  not  influenced  by  food,  not  preventing  sleep, 
often  relieved  by  lying  on  the  right  side.  She  thinks  there  has  been 
some  fever.  Her  family  history  and  previous  history  are  negative. 
She  has  six  well  children  and  two  dead.  Her  youngest  child  is  seven- 
teen.    Catamenia  ceased  two  months  ago. 

Physical  examination  showed  good  nutrition  and  was  otherwise 
negative  save  for  a  blowing  systolic  murmur  at  the  apex,  and  a  harsh 
systolic  murmur  at  the  base,  of  the  heart.  Physical  examination  of 
the  chest  was  negative.  In  the  right  lower  quadrant  was  a  hard, 
smooth,  tender  mass,  extending  to  the  navel  and  to  the  median  line 
(Fig.  7).  The  cervix  uteri  was  pushed  upward  and  forward,  the 
fundus  not  felt.  In  the  posterior  culdesac  was  a  hard,  sHghtly  nodu- 
lar mass,  the  size  of  a  lemon.     This  could  also  be  felt  by  rectum. 


42 


DIFFERENTIAL  DIAGNOSIS 


The  mass  shown  in  the  diagram  could  be  felt  bimanually.  The  blood 
and  urine  were  negative.  The  temperature  was  as  shown  in  the 
accompanying  chart  (Fig.  8).  On  the  19th  of  October  the  abdomen 
was  more  relaxed  and  the  mass  was  of  the  shape  shown  in  Fig.  9. 
Active  carthasis  produced  no  change  in  it.  Menstruation  began 
October  17th. 

Discussion. — We  are  confronted  here  with  a  pain  in  the  left 
lower  quadrant.  In  men  such  pain  ordinarily  means  cancer  of  the 
sigmoid  or  diverticulitis  of  the  same  region.     Tumors  due  to  hernia 


Physical  signs  in  Case  8,  October  15,  1908. 


or  to  swollen  glands  are  lower  down.     In  women  we  have  to  consider 
not  only  these  diseases,  but  those  arising  from  the  pelvis. 

When  we  come  to  the  physical  examination,  we  find  a  mass  not 
in  the  left,  but  in  the  right,  lower  quadrant.  Such  findings  often 
lead  us  to  disregard  the  history,  assuming  that  the  patient  must 
have  been  mistaken,  but,  as  the  outcome  of  this  case  shows,  such 
assumptions  are  dangerous.  Indeed,  I  think  the  habit  of  disregarding 
the  history,  provided  it  is  carefully  taken,  is  a  very  disastrous  one. 
Physicians  should  cultivate  the  sort  of  psychic  judgment  which  en- 


ABDOMINAL  AND    OTHER  TUMORS 


43 


ables  them  to  distinguish,  better  than  many  "scientifically  trained" 
physicians  do,  the  occasional  patient  whose  words  are  valueless,  and 
the  much  commoner  patient  whose  words  are  precious  as  guides,  but 
need  a  good  deal  of  interpretation.  A  lack  of  skill  in  history  taking 
seems  to  me  to  mislead  us  more  often  than  faulty  physical  exami- 
nation. 

Naturally,  one  first  considers  here  some  tumor  arising  from  the 
pelvic  organs,  especially  from  the  uterus  or  ovary.  The  mass  is 
obviously  too  large  for  any  inflammatory  exudate  starting  from  a 
tube.  It  might  conceivably  arise  from  the  pelvic  bones,  but  such 
tumors  are  very  rare.  That  it  is  not  at  all  influenced  by  active 
catharsis  renders  doubly  sure 
our  natural  assurance  that  it 
is  not  connected  with  the  in- 
testine. In  view  of  its  situa- 
tion— very  much  to  one  side  of 
the  median  Hne — and  consider- 
ing the  position  of  the  cervix 
and  the  mass  in  the  posterior 
culdesac,  it  seems  more  than 
probable  that  the  tumor  origin- 
ates in  an  ovary. 

Outcome. — The  mass  was 
believed  by  the  surgeon  to  be 
multiple  uterine  fibroids,  but 
at  operation,  October  24th,  two 
ovarian  cysts,  purple  and  about 
the  size  of  a  child's  toy  balloon, 
were  found  connected  with  each 
ovary.  Each  was  pedunculated, 
and  the  cyst  on  the  right  had  a  double  twist  of  its  pedicle,  but  had  not 
ruptured.  The  uterus  was  normal.  The  gall-bladder  was  distended  and 
full  of  stones,  but  was  not  molested.  The  cysts  were  removed.  Micro- 
scopic examination  by  Dr.  W.  F.  Whitney  showed  that  both  ovaries 
were  replaced  by  multilocular  cysts,  one  dark  red  and  filled  with 
hemorrhagic  fluid,  the  other  a  cystoma,  one  portion  of  which  was 
thickened  and  looked  slightly  medullary.  This  latter  portion  was 
made  up  of  dense  connective  tissue  in  which  were  some  gland-like 
growths,  lined  with  epithehal  cells.  Diagnosis,  cyst  adenoma.  The 
patient  made  an  excellent  recovery  and  left  the  hospital  November 
II,  1908,  apparently  in  excellent  condition. 


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44 


DIFFERENTIAL  DLA.GNOSIS 


Second  Entry. — She  entered  again  October  20,  1910,  having  re- 
mained well  in  the  previous  two  years  until  September,  1910,  when 
she  began  to  have  diffuse  abdominal  cramps,  with  more  than  usual 
constipation,  so  that  the  bowels  moved  only  about  every  three  days, 
although  without  medicine.  Eight  days  ago  she  had  an  especially 
severe  attack  of  cramps  and  next  morning  vomited  a  small  amount 
of  blood.  Yesterday  and  today  she  again  vomited,  this  time  greenish 
material.  Her  bowels  have  now  had  no  movement  for  seven  days. 
Her  chief  complaint  at  present  is  of  a  burning  sensation  at  the  ensi- 


Fig.  9. — Signs  in  Case  8,  October  19,  i 


form.  For  the  past  month  she  thinks  her  skin  has  been  growing 
yellow  and  her  urine  more  red.  At  times  of  late  she  has  had  severe 
sweating,  but  does  not  think  she  has  lost  any  weight. 

Physical  examination  showed  poor  nutrition,  no  jaundice,  mark- 
edly distended  abdomen,  tympanitic  in  the  lower  half,  slightly  tender 
throughout,  no  shifting  dulness  or  fluid  wave.  Pelvic  examination 
showed  a  round,  hard,  slightly  nodular  mass,  pushing  the  cervix  up 
behind  the  pubes  and  filling  all  the  vaults,  but  not  tender.  The 
patient's  blood  and  urine  were  normal.     On  the  21st  of  October  the 


ABDOMINAL  AND    OTHER   TUMORS  45 

abdomen  was  again  opened  and  the  pelvis  and  lower  abdomen  found 
filled  by  a  growth  surrounding  and  infiltrating  the  intestinal  walls. 
The  peritoneum  was  covered  with  small  nodules,  a  few  of  which  were 
excised  for  diagnosis.  Microscopic  examination  showed  a  solid  mass 
of  epithelial  cells  in  small  plexuses.  Diagnosis:  "Cancer."  The 
patient  recovered  well  from  the  operation  and  left  the  hospital  on 
the  28th  of  October,  1911.  A  letter  sent  March  13,  1913,  was  returned 
marked  "Dead." 

Postscript. — In  connection  with  what  was  said  above  as  to  the 
values  and  errors  of  the  patient's  own  account  of  his  troubles,  I  call 
attention  to  the  statement  made  by  this  patient  at  her  second  entry, 
that  her  skin  had  been  growing  yellow  and  her  urine  red.  I  have 
found  these  particular  statements  peculiarly  misleading.  One  is  apt 
to  take  them  as  evidences  of  jaundice  with  bile  in  the  urine,  but 
they  are  more  often  the  patient's  way  of  expressing  the  fact  that  his 
skin  is  yellow  or  anemic  rather  than  jaundiced,  and  that  he  happened 
to  notice  unusual  concentration  of  his  urine,  with  the  natural  in- 
crease of  color  associated  with  such  concentration.  At  the  time  of  the 
second  entry  it  seems  reasonable  to  beheve  that  the  patient's  symp- 
toms were  due  to  intestinal  obstruction,  depending  on  the  mass 
described  in  the  latter  part  of  the  preceding  paragraph. 

Case  9 

A  shoemaker  of  fifty- three  entered  the  hospital  November  12,  1908. 
The  patient's  family  history  and  past  history  were  not  of  importance. 
His  habits  were  good. 

Eight  years  ago  lumps  appeared  in  the  left  side  of  his  neck.  After 
the  first  few  months  they  have  not  enlarged  further.  A  year  ago 
additional  lumps,  larger  than  the  first  group,  appeared  in  the  neck. 
At  the  same  time  other  lumps  appeared  in  both  axillae  and  groins. 
Nine  months  ago  a  lump  appeared  in  the  rectum  and  one  in  the  region 
of  the  gall-bladder. 

Three  weeks  ago  the  abdomen  began  to  swell,  and  soon  after  the 
legs  also.  A  week  ago,  in  the  Out-patient  Department,  he  was  tapped 
and  2200  c.c.  of  ascitic  fluid  removed;  specific  gravity,  ion;  sediment, 
lymphocytic.  The  patient's  best  weight  was  180  pounds  a  year  and 
a  half  ago.  Just  before  the  abdomen  began  to  enlarge  he  weighed 
160  pounds.  His  appetite  is  now  good;  he  feels  in  most  respects  well 
and  complains  of  no  pain. 

Physical  examination  shows  fair  nutrition,  moderate  pallor. 
The  right  pupil  is  slightly  larger  than  the  left.     Both  react  normally. 


46 


DIFFERENTIAL  DIAGNOSIS 


All  the  reflexes  are  normal.  The  heart's  apex  is  seen  and  felt  in  the 
fifth  interspace,  12  cm.  to  the  left  of  midsternum  and  i|  cm.  outside 
the  nipple  line.  There  is  a  soft  systolic  murmur  in  the  pulmonary 
area;  othervvise  nothing  abnormal  on  auscultation.  The  lungs  are 
negative.  Abdomen  prominent,  navel  bulging.  Dulness  in  the 
flanks,  shifting  with  change  of  position.  Below  the  right  ribs  is  a 
hard,  smooth  mass,  internal  to  the  mammary  line,  not  adherent  to  the 
skin,  not  moving  with  respiration.  In  the  hypogastric  region  another 
mass  is  shown  in  the  diagram  of  November  12th  (Fig.  10).     Below 


Fig.  10. — Tumors  and  ascites  in  Case  9. 


the  angle  of  the  jaw,  on  the  left,  is  a  mass  of  glands,  8  by  10  cm.,  and 
elsewhere  in  the  neck,  axillas,  and  groins  are  lumps  the  size  of  a  bean 
to  that  of  a  hickory  nut.  The  epitrochlear  glands  are  palpable. 
The  liver  and  spleen  not  felt.  By  rectal  examination  a  nodular  mass, 
half  the  size  of  a  man's  fist,  pushes  inward  on  the  posterior  and  right 
wall.     Blood  and  urine  negative. 

Discussion. — With  multiple  lumps  in  the  abdomen  and  also  in 
the  neck,  axillae,  and  groins,  the  "snap  diagnosis"  would  naturally 
be  Hodgkin's  disease  (a  term  the  value  of  which  I  shall  discuss  in  a 


ABDOMINAL  AND    OTHER   TUMORS  47 

moment),  but  first  one  should  exclude,  if  possible,  tuberculosis  and 
syphilis  as  causes  of  general  glandular  enlargement. 

Tuberculosis  rarely,  if  ever,  produces  glandular  enlargement 
lasting  eight  years  without  any  suppuration.  It  would  be  almost 
certain  to  produce  fever  if  it  were  as  extensive  as  the  physical  signs 
indicate.  If  the  ascitic  fluid  were  part  of  a  tuberculous  process,  the 
specific  gravity  should  be  in  the  vicinity  of  1020. 

As  regards  syphilis,  there  are  few  if  any  cases  on  record  showing 
glandular  enlargements  of  anything  like  this  size  in  the  neck,  axillae, 
and  groins,  as  well  as  in  the  abdominal  glands.  So  extensive  a  process, 
if  due  to  syphilis,  would  probably  show  cutaneous,  oral,  osseous,  or 
visceral  changes.  In  this  case,  therefore,  it  seems  to  me  that  syphilis 
can  easily  be  ruled  out,  but  it  should  be  borne  in  mind  that  when 
glandular  enlargement  occurs  only  in  the  neck,  the  confusion  of 
syphilis  and  tuberculosis  is  not  unusual.  I  have  recently  seen,  with 
Dr.  Abner  Post,  a  case  of  s5^hiUtic  adenitis  of  the  neck  which  had  been 
treated  for  months  as  tuberculosis.  The  Wassermann  reaction  and  the 
results  of  treatment  soon  made  it  clear  that  the  adenitis  was  syphihtic. 

After  excluding  these  two  diseases,  the  affection  often  known  as 
Hodgkin's  disease  is  naturally  the  next  to  be  considered.  To  me  it 
has  become  increasingly  clear,  of  late  years,  through  the  studies  of 
the  most  accomplished  histologists,  that  there  is  no  proper  distinc- 
tion to  be  drawn  between  the  various  tumors  known  as  Hodgkin's 
disease,  lymphosarcoma,  malignant  lymphoma,  and  lymphatic 
leukemia,  except  that  in  the  latter  case  there  is  a  continuous  cir- 
culating metastasis  in  the  blood,  whence  the  term  "leukemia."  Why 
it  is  that  in  certain  cases  this  blood  metastasis  takes  place,  while  in 
other  cases,  histologically  identical,  there  is  no  multiplication  of  cells 
in  the  blood-stream,  no  one  has  yet  explained.  Meantime,  it  seems 
well  to  abandon  the  attempt  to  distinguish  the  various  types  of  dis- 
ease whose  names  I  have  just  listed.  Minor  differences  there  may  be. 
Clinical  varieties,  so  far  as  the  rate  of  progress  is  concerned,  there 
certainly  are.  A  case  of  malignant  lymphoma,  with  or  without  leu- 
kemia, may  remain  confined  to  a  few  small  neck  glands  for  years 
without  any  appreciable  harm  to  the  general  health.  In  other  cases 
the  spread  of  the  disease  and  the  constitutional  effects  are  fearfully 
rapid.     Between  these  two  extremes  there  is  every  grade  of  transition. 

To  render  the  diagnosis  certain  beyond  any  doubt  and  to  exclude 
syphilis  and  tuberculosis  finally,  a  gland  should  be  excised  in  every 
case  like  that  just  described.  The  operation  could  be  done  under 
local  anesthesia  and  is  of  no  risk  to  the  patient.     It  should  be  remem- 


48  DIFFERENTL\L   DIAGNOSIS 

bered,  however,  that  occasionally  in  the  vicinity  of  tuberculous  or 
otherwise  diseased  glands  one  often  finds  a  simply  hyperplastic  gland, 
which  when  excised  throws  no  Ught  upon  the  diagnosis.  Abdomi- 
nal glands  excised  from  the  vicinity  of  a  cancerous  tumor  often  give 
us  this  sort  of  misleading  and  disappointing  evidence,  and  seem  to 
tell  us  that  the  tumor  is  not  malignant  when  we  have  every  reason  to 
believe  that  it  is,  and  when  its  course  often  proves  it  to  be  so. 

Outcome. — A  gland  was  excised  from  behind  the  ear  and  showed 
structure  of  a  malignant  lym.phoma  (lymphoblastoma — Mallory). 
Coley's  serum,  every  second  day,  in  increasing  doses,  was  given, 
beginning  with  |  minim  and  working  up  to  12  minims.  A  febrile 
reaction,  sometimes  carrying  the  temperature  as  high  as  104°  F., 
followed  most  of  the  injections.  The  patient  often  has  a  chill  lasting 
an  hour.  The  abdomen  was  tapped  on  the  23d  and  82  ounces  of 
brownish-red  fluid  obtained.  It  was  tapped  again  on  the  4th  of 
December,  when  86  ounces  of  similar  fluid  were  removed;  specific 
gravity,  1015.  Smear  of  the  sediment  showed  mostly  epithelial 
cells.  On  the  third  tapping,  December  7th,  115  ounces  of  the  same 
fluid  were  obtained.  After  this  the  abdomen  continued  to  drain 
until  the  nth  of  December,  at  which  time  the  patient  began  to  be 
somewhat  drowsy.  By  the  14th  the  abdomen  was  again  filled,  but 
when  the  needle  was  inserted  the  fluid  would  not  run,  though  it 
drained  freely  from  the  tap-hole. 

About  this  time  diuretin,  15  gr.  four  times  a  day,  was  begun,  and 
the  amount  of  urine  rose  to  65  ounces,  with  considerable  improve- 
ment in  the  edema  of  the  legs.  On  the  20th  he  was  again  tapped, 
but  only  12  ounces  obtained.  The  tympany  now  extended  fairly 
well  into  the  flanks  and  but  little  fluid  could  be  obtained.  Upon  the 
23d  17  ounces  were  removed.  On  the  28th  a  loud  friction-rub  was 
heard' in  the  left  axilla  and  x-ray  showed  shadow  over  the  whole  left 
side  of  the  chest.  Another  course  of  diuretin  was  given,  beginning 
December  26th,  15  gr.  four  times  a  day.  The  urine  rose  to  62  ounces 
and  a  large  amount  continued  to  be  passed  for  three  days  more. 
On  the  29th  of  December  7  pints  of  fluid  were  removed  from  the 
abdomen,  after  which  he  felt  better  and  had  less  edema  of  the  legs; 
50  more  ounces  of  fluid  were  removed  January  2d;  specific  gravity, 
ion.  At  this  time  and  for  two  weeks  previously  x-ray  treatment  was 
used.  Other  tappings  occurred:  on  the  9th  of  January,  6  pints;  on 
the  14th,  106  ounces;  on  the  19th,  96  ounces.  The  patient  grew 
steadily  worse  and  was  discharged  on  the  21st  of  January.  He  died 
soon  after  at  home. 


ABDOMINAL   AND    OTHER  TUMORS  49 

Case  10 

A  housewife  of  thirty-nine  entered  the  hospital  September  9,  1905. 
Her  family  history  is  negative,  her  past  history  not  remarkable.     She 
has  had  three  children,  the  youngest  six  years  old.    Her  menstruation - 
is  irregular;  it  often  lasts  ten  days.      The  last  period  lasted   two 
weeks. 

Five  years  ago  she  began  to  have  dull  aching  pain  in  the  region 
of  the  left  hip  which  lasted  ten  days  and  then  left  her.  Ten  days  ago 
she  had  sudden  pain  in  the  left  side  of  the  chest,  following  an  attack 
of  indigestion.  It  was  sharp  at  the  beginning.  It  is  now  dull. 
Between  the  attack  five  years  ago  and  the  present  one  there  have 
been  some  seizures  similar  to  the  first.  She  thinks  in  the  attacks  that 
she  passes  less  urine  than  ordinary,  and  after  them,  more. 

Physical  examination  was  not  remarkable,  except  that  in  the 
upper  left  quadrant  there  was  a  sense  of  resistance  and  slight  tender- 
ness and  on  deep  breathing  the  tip  of  the  kidney  (or  spleen?)  was 
palpable.  An  indefinite  mass  below  this  was  felt,  which  seemed  to 
be  about  the  size  of  a  lemon.  Pelvic  examination  showed  in  front  of 
the  uterus,  in  the  median  line,  behind  the  pubes,  a  hard  mass  the  size 
of  an  egg.  The  uterus  was  retroverted;  not  otherwise  remarkable. 
The  urine  averaged  35  ounces  in  twenty-four  hours;  specific  gravity, 
1020;  slightest  possible  trace  of  albumin;  a  few  hyahne  and  fine  granu- 
lar casts,  some  with  red  cells  adherent.  The  blood  showed  30  per  cent, 
hemoglobin;  red  cells,  2,400,000;  leukocytes,  4000.  The  stain  smear 
showed  all  the  characteristics  of  secondary  anemia.  During  the 
first  week  of  her  stay  in  the  hospital  the  temperature  was  sHghtly  and 
irregularly  elevated  at  times,  the  highest  point  reached  being  100.8°  F. 

Discussion. — The  spleen  or  the  left  kidney  are  the  only  organs 
which  often  produce  a  mass  like  that  here  described.  Assuming  that 
we  were  correct  in  feeling  a  mass  behind  the  spleen,  we  must  be 
dealing  with  the  left  kidney.  We  have  also  to  account  in  some  way 
for  the  mass  behind  the  pubes  and  for  the  marked  secondary  anemia. 
Both  these  facts  would  lead  us  to  suppose  that  we  were  dealing  with 
a  neoplasm  from  which  metastasis  has  taken  place.  Since  hyper- 
nephromata  are  specially  prone  to  form  bony  metastases,  one  might 
surmise  that  the  hypergastric  lump  is  coimected  with  the  pubic  bone 
and  represents  such  a  metastasis.  Non-maHgnant  lesions  of  the 
kidney,  such  as  cyst  or  tuberculosis,  seem  improbable  on  account  of 
the  marked  anemia  which  is  not  often  found  in  these  diseases.  Reason- 
ing in  this  way,  the  clinical  diagnosis  of  the  case,  prior  to  operation, 
was  hypernephroma  with  menorrhagia. 

Vol.  II— 4 


50  DIFFERENTIAL  DIAGNOSIS 

Outcome. — September  13th  the  cervix  was  dilated  and  the  uterus 
was  steamed  forty  minutes,  then  wiped  out  with  gauze.  On  the  i8th 
of  September  the  hemoglobin  was  35  per  cent.;  September  29th 
hemoglobin  55  per  cent.  September  30th  an  incision  was  made  from 
just  above  the  left  anterior  superior  spine  of  the  ileum  for  5  inches, 
upward  and  outward.  Sections  carried  down  behind  the  peritoneum, 
and  a  cystic  tumor  was  revealed  in  the  region  of  the  kidney.  The 
cyst  was  ruptured  with  the  escape  of  clear  fluid.  No  kidney  sub- 
stance and  no  ureter  were  found.  Nothing  was  removed.  The 
patient  did  well  and  left  the  hospital  October  19,  1905.  November 
20,  1906,  the  patient  reported  by  letter  that  she  had  improved  steadily 
until  March,  1906,  and  at  that  time  seemed  perfectly  well. 

Soon  after  that  her  former  symptoms  recurred  and  have  persisted 
since.  December  20,  1908,  she  writes  that  she  has  aching  in  the  left 
side,  just  above  the  hip-bone,  following  down  toward  the  groin,  also 
a  backache  and  "a  large  bunch  reaching  toward  the  pit  of  the  stom- 
ach." She  has  attacks  of  gastric  distress  lasting  from  a  day  to  a 
week,  accompanied  by  a  scanty  urination  and  vomiting. 

She  re-entered  the  hospital  February  9,  1909,  stating  that  for  the 
past  year  she  had  many  attacks  of  pain  so  great  as  to  produce  nausea 
for  several  days  at  a  time.  In  these  attacks  a  mass  appears  in  the  left 
hypochondrium  and  gradually  increases  in  size.  At  first  it  is  only 
the  size  of  a  walnut,  later  as  large  as  the  fist.  Later  it  extends  into  the 
flank  and  grows  tender.  While  it  is  enlarging,  very  little  urine  is 
passed,  but  by  pressing  upon  the  mass  the  patient  can  cause  it  to 
disappear.  Simultaneously  she  feels  urine  accumulating  in  the 
bladder  and  can  then  pass  about  a  pint,  which  is  clear  and  without 
sediment.  Despite  these  symptoms  her  general  health  has  much 
improved  since  her  last  operation. 

Physical  examination  is  essentially  negative  except  for  a  mass 
in  the  left  hypochondrium  (Fig.  11),  which  is  smooth,  round, 
fluctuant,  not  tender,  moves  an  inch  with  respiration,  and  is  felt 
bimanually  in  the  flank.  Cystoscopy  by  Dr.  Lincoln  Davis  showed 
a  normal  bladder.  From  the  right  ureter  indigocarmin  was  ex- 
creted within  fifteen  minutes.  The  left  ureter  excreted  no  coloring- 
matter  whatever  during  half  an  hour's  observation.  On  the  14th  of 
February  the  mass  in  the  left  hypochondrium  increased  in  size  dur- 
ing the  day  so  that  at  night  it  was  the  size  of  a  grape-fruit  and  showed 
two  definite  lobes.  It  was  painful  and  fluctuant.  By  manipulation 
the  size  of  the  mass  was  considerably  decreased  and  the  pain  relieved. 
February  16,  1909,  the  old  scar  was  reopened  and  a  large  cystic 


ABDOMINAL  AND    OTHER   TUMORS 


51 


tumor  ruptured,  with  the  escape  of  a  pint  of  fluid  resembling  urine. 
This  time  the  remains  of  the  kidney  and  ureter  were  found  and  re- 
moved. Examination  by  Dr.  W.  F.  Whitney  showed  a  kidney  with 
a  very  large  dilated  pelvis,  one  end  of  which  extended  into  a  large  sac; 
the  ureter  very  small.  The  patient  did  well  after  operation  and  left 
the  hospital  on  the  i8th  of  March,  1909.  March  24,  1910,  the  patient 
reported  by  letter  that  she  has  been  perfectly  well  since  operation 
and  does  all  the  work  for  a  family  of  five.  When  in  the  hospital  she 
weighed  104  pounds;  now,  120  pounds. 


Fig.  II. — Mass  felt  in  Case  10. 

Postscript. — The  symptoms  which  the  patient  presented  during 
her  second  visit  to  the  hospital  were  obviously  those  of  intermittent 
hydronephrosis.  Presumably,  therefore,  that  disease  was  the  cause  of 
her  symptoms  throughout,  and  the  supposed  cyst,  opened  at  the  first 
operation,  was  a  hydronephrotic  sac.  The  cause  of  the  anemia  was 
probably  the  menorrhagia.  As  the  patient  has  now  been  under  ob- 
servation for  five  years,  it  seems  very  improbable  that  any  type  of 
malignant  disease  is  present.  As  to  the  mass  felt  near  the  pubic  bone 
at  the  first  examination,  I  can  only  say  that  it  was  forgotten  for  some 
time,  and  when  looked  for  again  was  not  to  be  found! 


52 


DIFFERENTIAL   DIAGNOSIS 

Case  11 


A  laborer  of  forty-five  entered  the  hospital  February  4,  1909. 
Family  history  and  past  history  not  interesting,  and  the  patient's 
habits  good.  Four  weeks  ago  the  patient  felt  perfectly  well.  He  was 
then  obliged  to  work  for  the  whole  of  one  day  in  the  wet,  cleaning  out 


Fig.  12. 


Fig-  13- 


a  cess-pool.  The  next  day  he  felt  all  right,  but  the  day  after  he  began 
to  have  pain  in  the  left  calf  and  in  the  inside  of  the  left  knee,  espe- 
cially on  getting  up  in  the  morning.  This  pain  compelled  him  to  stop 
work  and  increased  in  the  subsequent  days.  Lumps  upon  his  legs 
were  first  noticed  four  weeks  ago.  For  the  last  two  weeks  the  pain  has 
become  somewhat  "deadened,"  as  he  says,  and  the  swelling  is  less 


ABDOMINAL  AND    OTHER   TUMORS 


53 


marked.  Nevertheless,  he  has  been  confined  to  his  bed  practically 
all  the  time  in  the  last  four  weeks.  He  has  no  digestive  symptoms, 
no  cough,  no  loss  of  weight.     He  sleeps  poorly. 


cD 


Fig.  14. 

Physical  examination  shows  good  nutrition.  Pupils,  glands,  and 
reflexes  negative.  Chest  and  abdomen  negative.  On  the  right 
thigh,  in  the  middle  of  the  anterior  aspect,  is  a  hard,  tender  mass. 


54 


DIFFERENTIAL  DIAGNOSIS 


apparently  not  connected  with  the  skin,  nor  with  the  blood-vessels  or 
the  bones.  There  is  no  fluctuation  in  the  mass,  but  it  has  no  sharp 
limits.  The  size  and  situation  of  this  and  the  other  swellings 
present  in  the  case  is  shown  in  the  accompanying  diagrams  (Figs. 
12,  13,  14).  There  was  considerable  muscular  tremor  of  the  calves 
and  thighs.  When  the  patient  stood,  one  of  the  masses  became  bluish 
red.  The  course  of  the  temperature  is  shown  in  the  accompanying 
chart   (Fig.    15).     The  blood  and  urine   showed  nothing  abnormal. 

Drs.  Mixter  and  Brewster 
could  make  no  diagnosis.  Dr. 
H.  C.  Baldwin  thought  it 
probably  myositis,  and  noted 
increased  muscular  irritability. 
Dr.  F.  S_.  Burns  said,  *T  think 
that  trichiniasis  and  dermatitis 
coccidioides  should  be  con- 
sidered." A  swelling  on  the 
nasal  septum  was  examined  by 
Dr.  J.  P.  Clark  and  found  to 
be  nothing  but  a  slight  devia- 
tion covered  by  a  superficial 
excoriation. 

Discussion. — In  view  of  the 
obscurity  of  the  diagnosis  in 
this  case  and  of  the  great 
variety  of  opinions  expressed 
about  it  (I  have  quoted  only 
a  few  of  them  here),  it  seems  well  to  make  a  survey  of  the  whole  list 
of  affections  which  are  known  to  produce  multiple  subcutaneous 
lumps.     Such  a  list  is  as  follows: 

I.  V.  Recklinghausen's  disease,  or  neurofibromatosis. 

Nodular  lipomatosis  (''adiposis  dolorosa"),  with  or  without 

pain. 
Syphilis,  in  the  form  of  periostitis  or  gumma. 
Tuberculosis,  especially  osseous  and  periosteous. 
Sepsis  with  embolic  abscesses. 
Rheumatic  nodes. 

7.  Erythema  nodosum. 

8.  Urticarial    lesions,    with    or    without    associated    hemor- 
rhages. 

9.  Angiomata  or  lymphangiomata. 


lUsaL*'  iiU  li£.2./CjV/i/5^tf/4i2/§ 

i»<,.....-.      !■{      \r   1      ■    1  r---i  1-  /\li                         1 

ll                 l>iix»>aE|aiai>-E>iiiiir>isiit>iiEiEii>i  ai»t|«t, 

107 

IW 

101 

£  '« 

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330 

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Fig.  15.- — Chart  of  Case  11. 


2. 

3- 
4- 

5- 
6. 


ABDOMINAL  AND    OTHER  TUMORS  55 

10.  Malignant  lymphomata,  with  or  without  leukemia.     (Such 

growths  can  arise  from  the  minute  lymph-follicles  present 
in  the  deeper  layers  of  the  skin  and  in  the  subcutaneous 
tissues) . 

11.  Carcinomatosis. 

12.  Multiple  exostoses  (or  enchondromata). 

13.  Coccidioidal  granuloma. 

14.  Scurvy. 

15.  Myositis. 

16.  Actinomycosis. 

17.  Glanders.  ' 

18.  Leprosy. 

Differential  Diagnosis  and  Outcome. — ^Trichiniasis  does  not  pro- 
duce such  swellings.  The  encysted  embryos  produce  no  palpable  en- 
largement of  the  muscles.  Further  discussion  of  the  above  list  of 
possibiUties  will  follow  when  we  have  disposed  of  this  case.  The 
course  of  procedure  was  as  follows :  Within  a  few  days  one  of  the  tumors 
upon  the  arm  showed  distinct  fluctuation.  A  needle  was  introduced 
and  a  thick  pus  obtained.  There  were  many  trabeculae  running 
across  the  cavity.  On  the  loth  two  more  tumors  were  aspirated  and 
about  2  ounces  of  blood-stained  pus  obtained  from  each.  On  micro- 
scopic examination  well-preserved  leukocytes,  but  no  organisms, 
were  seen.  Dr.  James  H.  Wright  reported  that  the  smear  prepara- 
tions and  cultures  from  the  pus  showed  a  bacillus  not  inconsistent  with 
the  bacillus  of  glanders  in  morphology  and  cultural  pecuHarities.  A 
guinea-pig  which  had  survived  subcutaneous  injections  of  the  pus 
was  given  a  fresh  culture  intraperitoneally.  Two  days  later  the 
animal  died,  and  autopsy  showed  numerous  white  nodules  varying 
in  diameter  from  a  fraction  of  a  millimeter  to  several  millimeters, 
adherent  to  the  peritoneum  in  the  great  omentum,  in  the  testicles, 
and  elsewhere.  In  one  of  these  nodules  bacilli  like  the  bacillus  of 
glanders  were  found.     Diagnosis,  glanders. 

With  these  facts  in  our  possession,  the  patient  was  carefully  ques- 
tioned in  relation  to  his  association  with  horses,  but  no  such  history 
could  be  obtained,  though  he  admitted  that  he  had  slept  in  horse 
blankets.  On  the  i8th  he  was  transferred  to  the  surgical  service, 
where  he  ran  a  continuous  fever  between  99°  and  100°  Y.  for  four 
months.  The  pulse  during  this  time  ran  between  80  and  100.  The 
abscesses  were  very  slow  in  heahng.  April  8th  a  large  slough  was 
removed  from  the  left  leg.  May  nth  Dr.  C.  A.  Porter,  under  whose 
care  the  patient  was,  thought  there  was  thrombosis  in  the  iliac  vessels, 


56 


DIFFERENTIAL  DIAGNOSIS 


with  establishment  of  a  collateral  circulation  by  way  of  the  epigastric 
vessels.  May  15th  a  new  nodule  appeared  upon  the  arm  (Fig.  16). 
The  old  wounds  upon  the  arm  were  practically  healed  and  that  upon 
the  leg  was  gradually  getting  well.  May  20th  the  patient  was  dis- 
charged to  the  Out-patient  Department. 


,i 

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W^ 

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^. 

^l^[^^^HHpBPi 

M 

S^HPP 

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T 

/ 

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1 

f 

f 

^9Kn 

Fig.  16. — "Farcy  bud"  with  gangrene. 


The  patient  re-entered  the  hospital  December  30,  1909,  with  a 
persistent  ulcer  in  the  calf  of  the  left  leg,  all  his  other  wounds  having 
healed  properly  (Fig.  17).  This  ulcer  was  removed  with  a  consid- 
erable margin  of  skin  and  its  base  cure  ted.  As  there  was  some 
contraction  of  the  foot  on  this  side,  the  Achilles  tendon  was  cut. 
The  patient  left  the  hospital  January  7,  19 10. 


Fig.  17. — Glanders  ulcer  in  Case  ii. 

February  22,  1913,  Dr.  H.  Lincoln  Chase,  of  Brookline,  Mass., 
reports  that  patient  is  very  well  and  working,  though  there  is  still  a 
small  unhealed  ulcer  on  one  calf,  probably  corresponding  to  the  lesion 
shown  in  Fig.  17.  All  the  other  subcutaneous  abscesses  have  wholly 
healed. 

I.  Neurofibromatosis. — Returning  now  to  the  Ust  of  diseases 
producing  subcutaneous  lumps,   neurofibromatosis  usually  presents 


ABDOMINAL   AND    OTHER   TUMORS 


57 


no  difficulties  of  diagnosis  whatever.  It  is  a  rare  disease,  and,  if 
not  congenital,  appears  usually  early  in  life,  and  has  generally  existed 
for  many  years  practically  unchanged  before  we  have  any  oppor- 
tunity of  seeing  the  patient.  The  appearance  of  the  nodules  is  seen 
in  Fig.  1 8.  The  number  of  nodules  often  runs  into  the  hundreds  or 
into  the  thousands.  They  ordinarily  cause  the  patient  no  pain  or 
other  trouble,  and  he  seeks  advice  from  curiosity  or  apprehension. 
They  do  not  disturb  nutrition  or  general  health,  and  the  patient  often 


Fig.  i8. — Neurofibromatosis.     The  mother,  sister,  and  daughter  of  this  patient  all  had 

the  same  disease  (Bryan). 


lives  to  old  age.  A  few  of  them  are  sometimes  sensitive  to  pressure. 
Occasionally  nodules  within  the  spinal  canal  or  cranium  may  give  rise 
to  serious  symptoms  by  means  of  their  pressure.  The  tumors  are 
soft,  sometimes  pedunculated,  ordinarily  not  larger  than  a  chestnut. 
Occasionally  they  may  reach  enormous  size.  Histologically  they  are 
composed  of  nerve  substance  and  fibrous  tissue  in  var5Tng  pro- 
portions. Patches  of  brown  pigmentation  on  or  near  the  tumors 
are  frequent.     Some  of  the  nodes  may  contain  so  Httle  nerve  tissue 


58  DIFFERENTIAL   DLA.GNOSIS 

that  they  are  practically  fibromata,  but  there  is  no  need  to  establish  a 
separate  disease  entity  for  the  purpose  of  covering  these  slight  varia- 
tions from  the  ordinary  type. 

2.  Nodular'  Lipomatosis. — The  ordinary  subcutaneous  fatty  tumor 
so  frequently  seen  and  so  harmless,  is  sometimes  present  in  consider- 
able numbers  and  in  varying  sizes.  The  different  types  and  varieties 
of  this  trouble  have  been  described  and  photographed  by  Dr.  Irving 
P.  Lyon.^  As  a  rule,  these  lumps  are  wholly  symptomless  and  pain- 
less, and  the  physician  is  consulted  only  because  the  patient  wants  to 
be  reassured.  Occasionally,  however,  they  are  quite  painful,  like 
the  larger  areas  and  deposits  of  fat  first  described  by  Dercum  under 
the  term  "adiposis  dolorosa."  There  is  no  sharp  line  to  be  drawn 
between  the  small,  discrete,  painless  lipoma — single  or  multiple — 
and  the  extensive,  sometimes  symmetric,  deposits  of  fat  tissue— sensi- 
tive or  insensitive — over  various  parts  of  the  body.  The  diagnosis 
of  this  condition  rests  upon  the  feel,  the  lobulation  and  position  of 
the  tumors,  their  long  persistence  without  change  and  usually  with- 
out any  symptoms  whatever,  and,  in  the  last  resort,  upon  histologic 
examination  of  an  excised  specimen. 

3.  Syphilitic  periostitis  may  affect  a  number  of  bones  simul- 
taneously and  thus  give  rise  to  multiple  lumps.  It  is  often  painful 
or  tender.  The  connection  with  bone  can  usually  be  demonstrated 
by  palpation.  The  absence  of  suppuration,  the  evidence  of  syphilis 
elsewhere  in  the  body,  and  the  presence  of  a  Wassermann  reaction  are 
the  most  helpful  points  in  diagnosis.  Gummata  arising  in  the  sub- 
cutaneous tissues  are  not  likely  to  remain  long  without  ulcerations, 
hence  they  are  not  often  seen  as  subcutaneous  lumps.  They  are 
recognized  by  the  presence  of  other  evidences  of  syphilis  and  by  the 
exclusion  of  the  other  possibilities  now  under  discussion. 

4.  Tuberculosis. — This  lesion  does  not  often  give  rise  to  difficulties 
in  diagnosis,  as  it  is  very  prone  to  involve  the  skin  and  lead  to  sinus 
formation  and  suppuration.  Slow-healing  sinuses,  leading  to  necrotic 
bone,  are  more  often  tuberculous  than  anything  else.  Occasionally 
they  may  be  due  to  septic  osteomyelitis.  Other  lesions  of  tubercu- 
losis in  the  glands  or  internal  viscera  or  the  genito-urinary  tract  are 
often  present.  The  x-ray  appearances  are  ordinarily  characteristic. 
A  negative  Wassermann  reaction  may  be  of  great  value,  and  in  young 
children  a  positive  tuberculin  reaction  is  also  useful.  In  older  persons 
it  is  almost  or  quite  useless,  as  a  considerable  portion  of  them  give  a 
positive  reaction,  whether  they  are  actively  diseased  or  not. 

^The  Archives  of  Internal  Medicine,  July,  19 10,  vol.  vi,  pp.  28-120. 


ABDOMINAL   AND    OTHER   TUMORS  59 

5.  Sepsis  with  Embolic  Abscesses. — The  evidences  of  acute  inflam- 
mation and  the  rapid  accumulation  of  pus  ordinarily  makes  the  diag- 
nosis clear.  In  any  doubtful  case,  incision  and  culture  should  clear 
up  the  doubt. 

6,  Rheumatic  nodes  are  practically  confined  tendons  and  aponeu- 
roses (Figs.  19,  20,  21,  22,  23,  and  24).  One  sees  them  on  the  ten- 
dons of  the  wrists,  about  the  knuckles  and  near  the  elbow-joints  and 
knee-joints,  on  the  forehead  near  the  roots  of  the  hair,  and  about  the 
occiput.  They  are  practically  always  connected  with  other  manifes- 
tations of  that  form  of  streptococcus  infection  usually  called  acute 


Fig.  19. — Rheumatic  nodes  on  the  forehead.     These  wholly  disappeared  in  two  weeks. 

or  subacute  rheumatism.  Endocarditis  is  almost  invariably  present. 
It  follows,  therefore,  that  they  are  usually  seen  in  children,  rarely  in 
adults.  They  are  very  hard  and  almost  invariably  painless,  averaging 
the  size  of  a  small  pea,  but  their  most  characteristic  feature  is  the 
remarkable  fact  that  although  they  are  so  hard  that  it  seems  they 
must  last  forever,  they  may  absolutely  disappear  within  a  few  days  or 
weeks,  only  to  be  followed  by  new  crops.  Eventually  they  disappear 
for  good  and  all,  and  if  the  patient  conquers  his  endocarditis  he  may 
remain  in  full  health.  They  are  apt  to  be  confused  with  the  bony 
outgrowths  known  as  Heberden's  nodes  which  appear  on  the  termi- 
nal joints  of  the  fingers,  and,  once  established,  last  for  life.     The 


6o 


DIFFERENTIAL  DIAGNOSIS 


latter  have  no  connection  with  streptococcus  disease,  rheumatism, 
or  endocarditis. 

7.  Erythema    Nodosum. — Red,    painful,  sensitive    lumps   appear- 
suddenly  upon   the  flexor  surfaces  of  the  forearms  and  lower  legs, 


Fig.  20. — Rheumatic  nodes  on  elbow.     Same  case  as  Fig.  19. 

rarely  elsewhere  (Fig.  24.)  They  are  almost  never  suppurated  and 
ordinarily  disappear  within  a  few  weeks.  In  most  cases  they  are 
associated  with  joint  disturbances  and  often  with  endocarditis. 
They  are  usually  believed,  therefore,  to  represent  one  more  mani- 
festation of  the  picture  of  streptococcus  infection  above  referred  to. 


Fig.  21. — Rheumatic  node  on  wrist-tendon.     Same  case  as  Figs.  19  and  20. 


8.  Urticaria,  or  hives,  is  recognized  by  its  severe  itching,  its 
rapid  appearance  and  disappearance,  and  other  well-known  charac- 
teristics not  needing  further  description,  here.  It  may  be  associated 
with  joint  manifestations,  and  when  it  occurs  within  the  intestine, 


Case  i. 


Case  2. 


Female,  age  24,  6th  day  of  the  illness.  Female,  age  61,  17th  day  of  the  illness. 

Fig.  24. — Erythema  nodosum  (from  C.  Hegler,  Ergeb.  d.  Inn.  Med.,  1913,  p.  620). 


ABDOMINAL  AND   OTHER   TUMORS 


6i 


may  be  operated  upon  for  appendicitis,  as  in  the  case  described  in 
Vol.  I,  p.  447.  Similar  lesions  in  the  bronchial  mucous  membrane 
may  also  give  rise  to  acute  respiratory  symptoms.     (See  Vol.  I,  pp. 

73.  447-) 

9.  Angiomata  are  generally  bright  red  and  make  clear  their  nature 
by  their  color.     They  are  not  often  much  raised  above  the  surface. 


Fig.  22. — Rheumatic  nodes  on  finger-tendons. 

Between  them  and  the  ordinary  birth-mark  there  are  all  grades  of 
transition.  Lymphangiomata  seldom  produce  discrete  lumps,  but 
rather  misshapen  enlargements  of  a  part;  for  example,  of  the  hand  and 
forearm  or  of  the  foot.  They  fade  off  into  the  tissues  around  them. 
As  a  rule,  they  are  congenital  or  of  very  long  standing  before  a  medi- 
cal man  sees  them.     They  cause  no  symptoms,  and  advice  is  sought 


Fig.  23. — Rheumatic  nodes  on  finger-tendons. 


on  account  of  the  disfigurement.     Occasionally  we  find   combina- 
tions of  angiomata  and  lymphangiomata. 

10.  Malignant  Lymphomata. — So  long  as  mahgnant  lymphomata 
remain  confined  to  the  ordinary  sites  of  lymphatic  enlargement — 
the  neck,  the  axillae,  groins,  mesentery,  etc. — they  are  not  likely  .to 
be  confused  with  any  of  the  lumps  which  I  am  discussing  at  present. 


62 


DIPFERENTIAL  DIAGNOSIS 


Occasionally,  however,  and  especially  in  the  leukemic  varieties  of 
lymphoma,  we  have  nodules  in  the  subcutaneous  tissues  (Fig,  25). 
The  nature  of  these  will  not  be  suspected  unless  the  blood  is 
examined  or  unless  one  is  excised  for  histologic  study.  They  pre- 
sent no  distinguishing  characteristics  on  physical  examination.  They 
are  very  rare. 


Fig.  25. — Photograph  of  a  water-color  drawing  of  skin  nodules  in  a  case  of  myelemia. 
(By  kind  permission  of  Drs.  H.  D.  Rolleston  and  Wilfred  Fox.) 

II.  Carcinomatosis. — Multiple  foci  of  cancer  arising  in  the  skin, 
as  well  as  in  the  internal  organs,  sometimes  present  a  clinical  picture 
very  difficult  of  recognition. 

A  clerk  of  thirty-five,  who  handles  raw  pork  and  sometimes  eats 
it,  entered  the  hospital  May  13,  1913.     Ten  years  ago  he  had  syph- 


ABDOMINAL  AND    OTHER  TUMORS  63 

ilis.  Now  he  has  had  fever,  backache,  leg  ache,  cough,  and  diarrhea 
of  two  and  one-half  weeks'  duration.  The  entrance  diagnosis  was 
syphihs  cerebrospinal.  Physical  examination  (including  the  urine) 
was  negative  save  for  two  small  subcutaneous  nodules  on  his  chest, 
each  surrounded  by  a  hemorrhagic  area.  The  blood  showed  3,200,000 
reds,  gradually  falling  to  2,752,000.  No  achromia  or  deformities. 
May  25th,  12  normoblasts  per  100  leukocytes  (i.  e.,  1320  per  cubic 
millimeter).  Polynuclear  leukocytosis  (80  per  cent.)  at  entrance, 
gradually  falling  to  60  per  cent.  Eosinophils,  3  per  cent.;  the  rest 
lymphocytes.  The  total  leukocyte  count  varied  from  10,000  to 
18,000. 

During  the  next  two  weeks  he  sank  and  died  without  any  new 
symptoms  except  the  appearance  of  firm,  insensitive,  irregularly 
shaped  subcutaneous  nodules  in  various  parts  of  his  body.  The  largest 
was  1.5  cm.  in  diameter.  The  Wassermann  reaction  and  blood-culture 
were  negative.  There  was  a  good  deal  of  bleeding  from  the  nose  and 
rectum.  Coagulation-time  (venous  blood)  eight  to  sixteen  minutes. 
The  clinical  diagnosis  was  lymphatic  leukemia.  Autopsy  showed 
carcinoma  of  the  liver,  lungs,  pancreas,  spleen,  mesentery,  adrenals, 
pelvic  cavity,  epicardium,  pleura,  sternum,  vertebrae,  pelvic  bones, 
and  subcutaneous  tissue;  also  vegetative  endocarditis  (mitral),  with 
infarcts  of  the  spleen  and  subcutaneous  hemorrhages. 

12.  Multiple  Exostoses. — ^Aside  from  the  enlargements  of  the  ter- 
minal finger- joints  (Heberden's  nodes),  and  the  similar  but  less 
striking  enlargements  near  the  articular  surfaces  of  the  other  long 
bones,  the  occurrence  of  multiple  exostoses  is  very  rare.  Most 
of  what  is  known  upon  the  subject  has  been  recently  summarized  by 
Dr.  Channing  C.  Simmons  in  his  article  on  "LocaUzed  Osteomyelitis 
of  the  Long  Bones,"  which  appeared  in  the  "Boston  Medical  and 
Surgical  Journal"  of  May  i,  19 13. 

13.  Coccidioidal  granuloma  is  a  rare  disease  practically  confined  to 
CaUfornia  and  difficult  to  distinguish  from  blastomycosis.  It  seldom 
presents  subcutaneous  lumps  at  the  time  when  it  comes  imder  ob- 
servation, as  the  lesions  are  very  prone  to  involve  the  skin,  to  break 
down  and  produce  chronic  abscesses  or  lesions,  from  which  the  char- 
acteristic yeast-Hke  budding  organisms  can  be  easily  obtained,  in 
the  great  majority  of  cases.  Lesions  very  similar  to  those  of  tubercu- 
losis may  also  be  found  in  all  the  organs  which  tuberculosis  attacks. 
The  diagnosis  depends  upon  the  exclusion  of  S3^hiHs,  tuberculosis,  and 
malignant  disease,  and  upon  the  presence  of  characteristic  organisms 
on  coverslip  examination. 


64  DIFFERENTIAL  DIAGNOSIS 

14.  Scurvy. — Over  the  shins,  forearms,  and  near  the  insertion 
of  any  tendon  there  may  occur  in  scurvy  subcutaneous  hemorrhages, 
very  slow  of  absorption  and  producing  sHghtly  raised  tumors,  not 
imlike  those  of  syphilis  or  tuberculosis.  The  diagnosis  of  such  tumors 
is,  however,  perfectly  easy  in  the  majority  of  cases,  owing  to  the  other 
evidences  of  scurvy  in  the  patient  and  owing  to  the  conditions  of 
diet  revealed  by  the  history.  Such  swellings  are  usually  very  tender 
and  painful. 

15.  Myositis. — Those  who  practice  massage  probably  have  a 
much  greater  practical  knowledge  of  myositis  than  anyone  else, 
but  as  masseurs  seldom  have  an  adequate  medical  training,  they  have 
not  yet  succeeded  in  getting  their  observations  thoroughly  recognized 
by  medical  men.  Every  experienced  masseur  can  tell  us  how  often 
subcutaneous  indurations  are  discovered  during  the  course  of  a  treat- 
ment, and  how,  as  a  result  of  repeated  rubbings,  these  indurations 
may  be  removed.  Occasionally  such  forms  of  localized  myositis  form 
visible  and  palpable  lumps,  especially  about  the  occiput,  where  the 
neck  muscles  are  inserted.  They  are  much  larger  than  rheumatic 
nodules,  and  they  are  much  less  differentiated  from  the  surrounding 
tissues  and  often  much  less  tender.  Their  exact  relation  to  rheu- 
matic and  streptococcic  infection  is  not  clear.  Indeed,  very  little 
is  known  of  them,  as  very  few  histologic  examinations  have  been 
made. 

Besides  these  forms  of  low-grade  inflammation,  there  have  been 
reported,  especially  by  Japanese  observers,  a  good  many  cases  of  sup- 
purative myositis  occurring  in  discrete  foci  in  various  parts  of  the  body. 
Such  foci  are  to  be  differentiated  from  glanders  only  by  bacteriologic 
examination.  From  ordinary  subcutaneous  abscesses  they  are  dis- 
tinguished by  their  deeper  position.  Outside  of  Japan  very  few  such 
cases  are  on  record. 

16.  Actinomycosis,  involving  the  subcutaneous  tissues,  usually 
occurs  about  the  jaw,  in  the  neck,  or  over  the  elbows.  It  seldom 
produces  lumps,  but  forms  a  bluish,  porky,  suppurating  sinus  indis- 
tinguishable from  tuberculosis  of  gland  or  bone  unless  careful  micro- 
scopic examination  of  the  discharge  is  made  by  an  expert.  The 
disease  is  very  rare  and  is  usually  mistaken  for  tuberculosis  or  chronic 
osteomyelitis. 

17.  Glanders. — When  the  disease  has  become  generalized  and  is 
no  longer  confined  to  the  mucous  membranes,  it  often  manifests 
itself  by  subcutaneous  abscesses,  the  so-called  "farcy  buds"  of  the 
veterinarian,  which  must  be  remembered  in  human  as  well  as  in  equine 


ABDOMINAL  AND   OTHER  TUMORS  65 

glanders.  The  diagnosis  rests  upon  the  history  of  a  nasal  discharge 
in  one  closely  associated  with  horses,  and  upon  the  microscopic  ex- 
amination and  culture  of  the  pus  obtained  from  the  lesions. 

18.  In  leprosy  the  nodules  are  almost  all  upon  the  exposed  parts, 
especially  upon  the  hands  and  face,  though  it  is  beheved  that  the 
disease  most  often  starts  in  the  nasal  cavities.  No  description  of  the 
disease  will  be  attempted  here,  but  it  should  be  remembered  as  among 
the  possible  causes  of  subcutaneous  lumps,  especially  when  these 
occur  in  the  sites  just  mentioned. 

Aside  from  the  causes  of  subcutaneous  lumps  just  listed,  we  may 
mention  the  epiphyseal  enlargements  of  rickets  ordinarily  seen  at  the 
wrists,  ankles,  and  near  the  sternum.  The  deposits  of  sodium  biurate 
in  gout  sometimes  advance  along  the  tendons  to  a  considerable 
distance  from  the  joints.  The  pigmented  nodes  of  melanotic  sarcoma 
are  usually  secondary  to  similar  growths  in  the  eye  or  the  Hver,  but 
are  sometimes  mistaken  for  moles  or  warts.  Multiple  wens  about  the 
scalp  or  about  the  genitals  sometimes  give  rise  to  a  good  deal  of  doubt 
and  apprehension  on  the  patient's  part,  and  even  a  physician  is  some- 
times in  doubt  as  to  their  nature  unless  he  investigates  their  contents 
and  recognizes  the  greasy,  sebaceous  material  with  which  they  are 
filled.  I  recently  mistook  a  soft  metastatic  neoplasm  of  the  scalp  for 
a  wen. 

Case  12 

A  housewife  of  twenty-nine  entered  the  hospital  February  23,  1909. 
The  patient  was  sent  in  from  the  Out-patient  Department  with  a 
diagnosis  of  "retroperitoneal  cyst  (?)."  The  patient's  husband  died 
eight  months  ago  of  phthisis.  The  patient  took  entire  care  of  him. 
Her  family  history  is  good,  but  since  the  age  of  sixteen  she  has  had 
paroxysmal  epigastric  pain  in  attacks  lasting  a  few  minutes  at  short 
intervals  for  periods  of  three  or  four  days  and  recurring  at  intervals  of 
weeks  or  months.  She  sometimes  has  to  go  to  bed  with  these  attacks. 
Occasionally  the  pain  is  in  the  lower  abdomen.  It  does  not  radiate, 
has  no  relation  to  meals,  and  is  never  associated  with  jaundice  or 
changes  in  the  urine.     It  is  often  accompanied  by  vomiting. 

Eight  years  ago  her  appendix  was  removed  in  the  hopes  of  reHev- 
ing  the  trouble,  but  no  relief  followed.  Her  appetite  is  good,  her 
bowels  habitually  constipated.  Her  menstruation  is  irregular,  often 
skipping  a  period. 

Two  years  ago  she  noticed  that  her  corsets  seemed  abnormally 
tight  about  the  waist,  especially  just  below  the  ribs  in  front.     Soon 

Vol.  II— 5 


66 


DIFFERENTLA.L  DIAGNOSIS 


after  this  a  swelling  became  visible  and  palpable  in  the  epigastric 
region.  This  tumor  has  increased  considerably  in  size  in  the  past 
year  and  the  whole  abdomen  seems  somewhat  larger.  The  tumor  also 
seems  to  be  growing  firmer.  It  throbs  and  beats.  Her  weight  has 
been  shghtly  increasing  for  a  year.  For  the  past  six  weeks  her  face 
has  been  puffy,  especially  about  the  eyes,  and  she  is  somewhat  short 
of  breath,  which  she  accounts  for  as  due  to  the  pressure  of  the  tumor. 
Physical  examination  shows  good  nutrition,  many  small  papules 
over  the  back,   shoulders,  and  neck.     Pupils,  glands,   and  reflexes 


Fig.  26. — Signs  in  Case  12. 


normal.  When  she  lies  on  her  left  side  a  faint  presystolic  roll  can  be 
heard  at  the  apex ;  otherwise  the  heart  is  not  abnormal.  The  lungs  are 
negative.  Between  the  ensiform  and  the  navel  is  a  rounded,  tense 
prominence,  about  5  by  7  inches,  dull  on  percussion  in  its  upper  two- 
thirds.  During  examination  the  tumor  seems  to  vary  somewhat 
in  size.  The  rest  of  the  abdomen  is  tympanitic  except  in  the  flank, 
where  there  is  dulness,  not  shifting  with  change  of  position.  No 
fluid-wave  can  be  demonstrated  and  there  are  no  other  masses.  The 
epigastric  tumor  is  moderately  tender.  No  respiratory  mobiHty  can 
be  demonstrated.     There  is  notable  tenderness  in  both  costovertebral 


ABDOMINAL  AND    OTHER   TUMORS  67 

angles.  Leukocytes,  8500;  hemoglobin,  90  per  cent.  Urine  normal. 
No  fever  in  ten  days'  observation.  The  possibilities  considered  were 
retroperitoneal  cyst,  connected  with  the  pancreas  or  kidney,  hour- 
glass stomach,  lipoma  of  the  abdominal  wall,  and  phantom  tumor. 
Inflation  of  the  stomach  showed  that  the  tumor  was  displaced  or 
overridden  by  it  (Fig.  26).  The  capacity  of  the  stomach  was  40 
ounces.  After  a  test-meal  free  HCl  was  0.09  per  cent. ;  total  acidity, 
0.2  per  cent. 

Discussion. — The  history  gives  us  nothing  definite.  The  essen- 
tials of  physical  examination  are  the  epigastric  tumor  of  long  dura- 
tion, occurring  in  a  well-nourished  woman  of  twenty-nine.  Such  a 
tumor  obviously  presents  something  out  of  the  ordinary,  for  epigastric 
tumors  ordinarily  occur  in  emaciated  old  people  (cancer  of  the  stom- 
ach) and  are  not  of  long  duration. 

We  must  consider  a  pancreatic  cyst,  which  is  a  benign,  slow- 
growing  affair,  and  may  occur  at  any  age.  Such  a  cyst  can  be  recog- 
nized only  by  ruling  out,  through  extensive  examination,  any  disease 
of  the  stomach,  liver,  and  spleen,  and  then  by  tapping  the  cyst  and 
examining  its  fluid  for  the  presence  of  pancreatic  ferments.  If  the 
function  of  the  pancreas  is  seriously  interfered  with,  we  may  have 
glycosuria  or  fatty  stools.  In  this  case  the  urine  and  the  feces  were 
normal.  There  was  no  evidence  of  disease  of  the  stomach,  liver,  or 
spleen.  The  tumor  was  not  tapped  for  reasons  apparent  in  the  out- 
come. 

Retroperitoneal  new-growth,  ordinarily  malignant  lymphoma, 
would  probably  have  been  associated  with  ascites,  emaciation,  and 
pain.  Other  tumors  would,  in  all  probability,  be  demonstrable  within 
or  without  the  abdominal  cavity.  The  blood  might  show  leukemic 
characteristics. 

The  excellent  condition  of  the  patient  makes  us  wonder  whether 
the  mass  may  not  be  in  the  abdominal  wall.  A  mass  of  fat  or  one 
of  the  bellies  of  the  rectus  sometimes  becomes  perceptibly  prominent, 
and  leads  the  patient,  as  well  as  the  physician,  to  suppose  that  some 
disease  exists.  These  possibilities  could  not  be  excluded  in  this  case. 
No  positive  diagnosis  was  made. 

Outcome. — On  the  3d  of  March  the  patient  was  etherized  and  the 
tumor  wholly  disappeared,  promptly  reappearing  when  she  came 
out  of  the  ether.  Apparently  it  was  a  "phantom  tumor."  She  left 
the  hospital  on  the  4th  of  March. 


68 


DIFFERENTIAL  DIAGNOSIS 


Case  13 

A  woman  of  sixty- two  entered  the  hospital  April  21,  1909.  A 
year  ago  she'  had  an  attack  called  ''inflammation  of  the  bowels." 
She  has  also  had  two  previous  attacks,  rather  vaguely  dated.  In 
each  she  had  diarrhea,  without  blood,  but  with  much  pain  in  the  left 
side  of  the  abdomen.  Since  the  last  attack,  a  year  ago,  she  has  never 
been  strong,  and  has  never  been  free  from  pain  in  the  left  side  of  the 
abdomen.  For  four  or  five  months  this  pain  has  been  quite  severe  at 
times,  occasionally  cramp-like.     Hot  applications  relieve  it. 


Fig.  27. — Mass  felt  in  Case  13. 


Nearly  a  year  ago  she  noticed  in  the  region  of  pain  a  lump  the 
size  of  her  fist.  For  some  time  she  has  been  losing  weight  and  strength, 
and  for  a  year  she  has  done  no  regular  work.  Her  appetite  is  good 
except  when  the  pain  is  bad;  then  she  vomits  everything.  Her 
bowels  move  daily. 

Physical  examination  shows  fair  nutrition  and  is  in  all  respects 
negative  except  as  relates  to  the  upper  left  quarter  of  the  abdomen, 
where  there  is  a  hard,  irregular,  slightly  movable  mass,  not  descending 
with  respiration,  slightly  tender.  The  colon  traverses  it  (Fig.  27). 
Blood,  urine,  and  feces  normal.     No  fever  in  a  week's  observation. 


ABDOMINAL  AND    OTHER  TUMORS  .69 

Discussion. — Diarrhea  and  crampy  pain  in  an  emaciated  patient 
of  sixty-two,  with  a  lump  in  the  left  upper  quadrant,  suggests  at  once 
a  carcinoma  of  the  splenic  flexure.  The  fact  that  the  bowels  move 
daily  does  not  exclude  such  a  disease.  The  absence  of  blood  in  the 
feces  is  more  definite  evidence  against  cancer  of  the  colon.  Still 
more  important  as  negative  evidence  is  the  fixity  of  the  tumor  and  its 
size.  So  extensive  a  neoplasm  connected  with  the  intestine  would 
almost  certainly  have  given  rise  to  marked  obstructive  symptoms. 

May  not  the  tumor  be  connected  with  the  kidney?  That  the 
colon  traverses  it  is  wholly  in  favor  of  such  a  supposition,  and  the 
negative  condition  of  the  urine  does  not  rule  it  out,  though  with  a 
tumor  of  so  great  a  size  one  would  expect  a  hematuria  sooner  or  later. 

Tumors  arising  in  the  tail  of  the  pancreas  are  rare,  and  if  they 
attained  so  great  a  size  would  probably  show  some  deficiency  of  pan- 
creatic function,  manifested  in  the  stools  or  urine. 

Retroperitoneal  tumors  arising  from  the  prevertebral  glands  often 
give  rise  to  ascites  and  to  fever.  The  amount  of  pain  associated  with 
them  varies  greatly.  It  is  often  not  greater  than  in  this  case.  After 
considerable  study  and  after  excluding,  so  far  as  possible,  the  other 
alternatives  considered  above,  I  made  the  diagnosis  of  retroperitoneal 
neoplasm  in  this  case. 

Outcome. — Dr.  C.  A.  Porter  thought  the  tumor  retroperitoneal, 
possibly  sarcoma  of  the  pancreas,  the  fixedness  of  the  mass  suggesting 
this.  April  25th  Dr.  Porter  opened  the  abdomen  and  found  a  tumor, 
the  size  of  two  fists,  springing  from  the  retroperitoneal  tissues  on  the 
level  with  the  lower  border  of  the  left  kidney.  Further  exploration 
showed  in  the  pelvis  a  hard,  irregular  mass,  the  size  of  an  orange, 
apparently  connected  with  the  left  ovary.  The  left  broad  Hgament 
was  thickened  and  nodular.  Between  the  first  tumor  and  the  pelvic 
mass  just  described  there  was  another  retroperitoneal  swelling,  about 
2  inches  wide  and  nodular.  The  gastro-intestinal  tract  was  wholly 
uninvolved.  No  attempt  was  made  to  remove  the  mass.  There 
was  no  vaginal  examination  previous  to  operation.  The  patient 
recovered  from  the  operation  and  left  the  hospital  on  the  13  th  of 
May,  but  died  seven  weeks  later,  after  much  suft'ering. 

Case  14 

An  automobile  repairer  of  twenty-four  entered  the  hospital  De- 
cember 7,  191 1.  The  patient's  family  history  is  negative  and  he  has 
had  no  previous  disease.  For  the  past  three  weeks  he  has  noticed  a 
lump  in  his  right  armpit.     It  caused  no  pain  or  discomfort  until  a 


70  DIFFERENTIAL  DIAGNOSIS 

week  ago.  Since  then  the  pain  has  been  increasing  and  now  he  is 
unable  to  work.  For  a  month  he  has  noticed  some  headaches,  but  no 
defect  in  sight.     His  eyes  have  not  been  examined. 

Physical  examination  is  negative,  except  for  the  right  axilla, 
where  there  is  a  soft,  tender,  rounded  mass  of  doughy  consistency, 
about  the  size  of  a  large  plum. 

Discussion. — A  lump  in  the  right  armpit,  noticed  for  three  weeks, 
painful  for  one  week  only,  is  not  at  all  likely  to  be  due  to  any  form  of 
neoplasm.  Such  growths,  if  occurring  in  the  axilla,  are  almost  in- 
variably bilateral  and  accompanied  by  similar  tumors  in  the  neck 
and  groins. 

Much  more  probable  is  a  tuberculous  or  septic  type  of  adenitis. 
The  absence  of  any  evidence  of  tuberculosis  in  any  other  part  of  the 
body  and  the  good  previous  history  and  family  history  make  us 
incline  toward  a  septic  type  of  adenitis.  Deep  axillary  abscesses, 
which  have  already  been  referred  to  on  pages  334  and  484  of  Vol.  I, 
should  be  recognized  as  a  distinct  clinical  entity  of  insidious  course, 
and  are  often  unrecognized  because  the  pus  is  situated  so  deeply, 
pressing  into  the  foreground  swollen  glands  which  often  engross  the 
physician's  attention  and  mask  the  existence  of  any  other  disease. 

Outcome. — December  8th  the  axillary  mass  was  cut  open  and  2 
ounces  of  thick  yellow  pus  removed,  revealing  the  tumor  proper. 
Complete  dissection  was  carried  round  the  tumor,  cleaning  out  the 
entire  axillary  structures,  including  the  brachial  vein.  The  mass 
thus  removed  was  hard  and  about  4  by  4  cm.  Microscopic  examina- 
tion showed  lymph-nodes  with  sHght  h3rpertrophy  of  the  lymphoid 
elements  and  a  hemorrhagic  infiltration  of  the  surrounding  tissues. 
The  glands  varied  in  size  from  that  of  a  pea  to  an  English  walnut. 
The  microscopic  diagnosis  was  chronic  inflammation.  The  patient 
promptly  recovered  and  left  the  hospital  on  the  nth  of  December. 
There  has  been  no  recurrence  (1914). 

Case  15 

A  coachman  of  thirty-seven  entered  the  hospital  June  10,  1909. 
Five  years  ago  the  patient  noticed  a  mass  in  the  left  side  of  his  ab- 
domen. He  is  quite  sure  that  that  lump  is  the  same  which  is  now 
palpable  there.  For  the  first  two  years  this  grew  steadily  in  size. 
He  then  began  to  have  x-ray  treatment  and  has  had  it  two  or  three 
times  a  week  for  the  past  three  years.  Under  this  treatment  he  has 
felt  very  well  and  has  worked  until  three  weeks  ago.  About  six 
months  ago  he  began  to  cough,  and  this  symptom  continues. 


ABDOMINAL  AND   OTHER  TUMORS  7 1 

Three  weeks  ago  he  began  to  feel  weaker  and  had  to  give  up  work. 
During  this  period  his  throat  has  been  sore  and  swollen.  He  has  also 
had  dyspnea  and  edema  of  the  feet.  At  the  beginning  of  this  illness, 
five  years  ago,  he  weighed  i8o  pounds,  with  clothes;  now,  152  pounds, 
without  clothes.  The  following  notes  from  the  out-patient  record 
show  his  condition  three  years  ago:  October  6,  1906,  Weight,  160 
pounds;  hemoglobin,  70  per  cent.  The  liver  reaches  from  the  sixth 
rib  to  a  point  8  cm.  below  the  costal  margin.  Spleen  16  cm.  below 
the  costal  margin,  in  the  nipple  line  and  6  cm.  to  the  right  of  the 
umbilicus.  White  cells,  49,200;  red  cells,  4,072,000;  lymphocytes, 
95  per  cent.  February  7,  1907,  White  cells,  11,300;  lymphocytes,  75 
per  cent.  Spleen  much  smaller.  April  30,  1907,  White  cells,  8200. 
May  8,  1908,  Hemoglobin,  90  per  cent.  The  Hver  still  reaches  2  cm. 
below  the  costal- margin.  August  2, 1908,  White  cells,  11,200;  lympho- 
cytes, 89  per  cent.  April  9,  1909,  White  cells,  20,000;  hemoglobin, 
85  per  cent.;  lymphocytes,  98  per  cent. 

Physical  examination  June  10,  1909,  showed  fair  nutrition,  sHght 
pallor,  slight  enlargement  of  the  tonsils,  moderate  enlargement  of 
the  cervical,  axillary,  inguinal,  and  epitrochlear  glands.  The  heart  was 
negative,  save  for  a  blowing,  systolic  murmur,  loudest  at  the  apex, 
transmitted  to  the  axilla.  Lungs  negative.  The  liver  edge  was  felt 
6  cm.  below  the  ribs,  in  the  nipple  line.  Its  dulness  extended  to  the 
sixth  rib  above.  Its  surface  was  slightly  tender.  The  lower  edge  of 
the  spleen  was  20  cm.  below  the  costal  margin;  its  right  border  at  the 
umbilicus;  its  surface  hard,  sHghtly  irregular,  not  tender.  There  was 
moderate  soft  edema  of  the  lower  legs,  a  considerable  discoloration  of 
the  skin  over  the  shins  and  over  the  spleen.  The  red  cells  during  the 
month  of  his  stay  in  the  hospital  gradually  decUned  from  1,750,000  to 
750,000.  The  white  cells  at  entrance  were  19,000;  fell  a  week  later  to 
13,000;  then  gradually  rose  to  20,000.  The  lymphocytes  made  up 
from  95  to  99  per  cent,  of  all  the  white  cells  present.  Most  of  them 
were  of  the  smaller  type,  but  the  large  forms  grew  more  numerous 
toward  the  end  of  the  patient's  stay. 

At  entrance  there  was  some  achromia,  but  this  disappeared  gradu- 
ally, and  toward  the  last  of  his  stay  the  color-index  was  decidedly 
high.  Examination  of  the  fundus  ocuK  showed  numerous  hemor- 
rhages throughout  the  retina  of  each  eye.  The  temperature  during 
the  first  three  weeks  of  his  stay  ranged  most  of  the  time  between  99° 
and  100°  F.,  rarely  touching  normal.  In  the  fourth  week  it  became 
subnormal.  The  patient  was  given  atoxyl  solution,  5  minims  sub- 
cutaneously,  once  a  day.     Later  this  was  omitted  and  15  minims  of  the 


72  DIFFERENTIAL  DIAGNOSIS 

green  citrate  of  iron  were  administered  subcutaneously  every  second 
day.     Still  later  Fowler's  solution  was  tried. 

Discussion. — When  a  man  notices  a  lump  in  his  abdomen  it  is 
generally  a  spleen.  An  enlarged  liver  is  not  nearly  so  often  found, 
and  tumors  of  the  stomach  are  rarely  found  by  the  patient  himself. 
In  women,  pelvic  tumors,  especially  uterine  fibromyoma,  are  more 
apt  to  be  fovmd  by  the  patient  herself. 

The  enlarged  spleen  thus  found,  if  it  occurs  in  a  temperate  climate, 
is  most  often  due  to  leukemia.  The  blood  examination  of  this  case 
leaves  no  doubt  that  leukemia  of  the  l3niiphoid  type  is  the  diagnosis. 
Attention  may  be  called  to  the  following  points: 

First,  The  long  duration  of  the  case  under  :r-ray  treatment.  It 
seems  to  me  very  doubtful  whether  this  patient  would  have  Hved 
and  worked  three  years  after  the  diagnosis  was  made  unless  he  had  had 
the  advantage  of  x-ray  treatment. 

Second,  The  long  latent  period  of  the  disease.  The  mass  was 
noticed  at  least  five  years  before  his  present  entry  to  the  hospital. 
I  have  seen  at  least  three  patients  with  lymphoid  leukemia  and 
enlarged  cervical  lymph-nodes  who  stated  very  positively  that  these 
lymph-nodes  had  been  present  for  thirty  or  forty  years,  i.  e.,  since 
childhood.  Presumably  the  blood  during  the  greater  part  of  this 
period  was  normal.  In  other  words,  the  tumors  which  Dr.  F.  B. 
Mallory  teaches  us  to  call  lymphoblastoma^  often  remain  for  many 
years  non-leukemic.  Why  they  finally  begin  to  discharge  cells  into 
the  blood  we  do  not  know. 

Third,  Note  that  the  liver  as  well  as  the  spleen  is  considerably  en- 
larged, yet  was  not  noticed  by  the  patient  himself. 

Outcome. — Despite  all  attempts  at  drug  treatment,  the  patient 
lost  ground  steadily,  and  by  the  4th  of  July  had  considerable  ascites. 
The  patient  desired  to  go  home,  and  left  the  hospital  on  the  7th  of  July. 

Case  16 

A  baker  of  forty-five,  a  Scotchman,  entered  the  hospital  July  16, 
1909.  After  an  uneventful  Hfe  the  patient  began  ten  months  ago  to 
have  severe,  steady  pain  in  the  right  side  of  the  abdomen.  He  be- 
came so  weak  that  he  went  to  bed  for  a  month,  though  the  pain  was 
gone  in  about  two  weeks.  When  he  got  up  his  legs  began  to  swell  and 
have  remained  swollen  ever  since,  though  he  has  regained  some  strength. 
He  has  been  imable  to  work  for  ten  months.     Six  months  ago  he 

^  Principles  of  Pathologic  Histology,  Frank  B.  Mallory,  p.  326,  W.  B.  Saunders  Co., 
1914. 


ABDOMINAL  AND   OTHER   TUMORS  73 

noticed  enlargement  of  the  abdomen.  He  has  coughed  all  his  life, 
he  says;  no  more  now  than  previously.  It  is  his  habit  to  take  four  or 
five  drinks  of  whisky  a  day.  The  present  swelling  in  his  legs  began 
also  ten  months  ago.  His  usual  weight  is  140  pounds,  with  clothes; 
at  entrance,  i28f  pounds,  without  clothes. 

Physical  examination  shows  poor  nutrition  and  pallor.  The 
cervical,  submaxillary,  axillary,  and  inguinal  glands  are  enlarged, 
some  to  the  size  of  a  pigeon's  egg,  some  to  the  size  of  a  hen's  egg.  The 
heart's  impulse  extends  2  cm.  outside  the  nipple  line,  the  right  border 
3^  cm.  from  midsternum.  There  is  a  slight  systolic  murmur  at  the 
apex  transmitted  to  the  axilla.  Pulmonic  second  sound  is  not  ac- 
centuated. The  lungs  are  negative  save  for  flatness,  absent  breath- 
ing, and  fremitus  below  the  angle  of  each  scapula  behind. 

The  abdomen  shows  tumor  masses,  one  in  the  suprapubic  and 
right  iliac  region,  another  under  the  right  ribs.  There  is  also  a 
suggestion  of  a  mass  in  the  neighborhood  of  the  navel.  The  rest  of 
the  abdomen  is  occupied  by  fluid.  The  veins  over  the  abdomen  are 
considerably  enlarged. 

Dufing  six  weeks'  observation  the  patient  had  no  temperature, 
but  gradually  lost  5  pounds.  The  urine  was  negative.  The  blood 
showed  red  cells  2,760,000  at  entrance,  and  this  figure  did  not  vary 
much  during  the  period  of  observation.  The  hemoglobin  gradually 
rose  from  65  to  nearly  80  per  cent.  The  white  cells  ranged  from 
85,000  to  100,000,  over  95  per  cent,  of  them  being  small  lympho- 
cytes, with  a  few  per  cent,  of  large  lymphocytes.  The  red  cells  showed 
considerable  achromia,  slight  deformities,  no  nucleated  forms. 

Discussion. — In  view  of  the  blood  examination,  there  can  be 
no  considerable  doubt  of  the  diagnosis  in  this  case.  It-differs  from  the 
last  case,  notably,  in  the  presence  of  pain.  In  my  experience  pain  is 
much  more  apt  to  be  present  in  those  cases  of  leukemia  arising  from 
abdominal  tumors  outside  the  spleen  and  liver  or  from  thoracic  tumors. 
When  the  main  growths  are  in  the  cervical,  axillary,  or  inguinal 
lymph-glands  or  are  confined  to  the  spleen  and  Hver,  the  patient  does 
not  usually  complain  of  pain,  but  when,  as  in  the  present  case,  we 
have  masses  arising  from  the  abdominal  l5rmph-glands  and  pressing 
forward  beneath  the  abdominal  wall,  pain  is  usually  more  or  less 
troublesome.  The  association  with  ascites  is  to  be  expected,  since 
the  enlarged  glands  and  extraglandular  masses  surround  and  com- 
press the  vascular  root  of  the  mesentery. 

The  commonness  of  these  lymphoblastic  tumors  without  leukemic 
blood  has  been  concealed,  to  a  certain  extent,  from  our  recognition  on 


74  DIFFERENTIAL  DIAGNOSIS 

account  of  complications  in  temiinology.  We  have  called  them  sar- 
coma, l;yTnphosarcoma,  and  laid  stress  upon  the  particular  organ  in 
which  they  arise.  But  if  their  fundamental  similarity  in  structure  is 
recognized,  it  will  be  seen  that  tumors  of  this  general  type,  the  type 
which  may  or  may  not  be  associated  with  leukemic  blood  (lymph- 
emia),  are  not  at  all  uncommon. 

Note  that  in  this  case  the  hemoglobin  showed  considerable  improve- 
ment, but  the  patient  did  not.  Such  discrepancies  are  not  infrequent 
and  remind  us  that  the  blood  represents,  after  all,  only  a  minor  feature 
of  the  disease.  In  some  cases  the  patient  gets  much  better,  although 
his  blood  remains  unchanged. 

Outcome. — The  patient  had  a;-ray  treatment,  but  showed  no  con- 
siderable improvement,  and  left  the  hospital  August  25th. 

Case  17 

A  farmer  of  thirty-eight  entered  the  hospital  August  5,  1909.  The 
patient  has  an  excellent  family  history  and  has  always  been  well  and 
strong  until  last  fall,  when  he  was  operated  upon  for  appendicitis.  His 
habits  are  good.     He  denies  venereal  disease. 

After  the  operation  he  did  not  regain  his  strength,  and  began  to 
notice  that  any  considerable  exertion  caused  an  ache  in  the  right  side 
of  his  abdomen,  though  there  was  no  sharp  pain  such  as  he  had  had 
before  the  operation.  This  ache  has  gradually  become  continuous  and 
now  disturbs  sleep.  Occasionally  the  ache  extends  to  the  right  leg 
or  to  the  genitals.  For  one  month  he  has  had  to  pass  urine  four  or 
five  times  daily  and  once  or  twice  at  night.  Eating  seems  to  increase 
his  discomforts  and  his  appetite  is  poor.  He  thinks  he  has  lost  5  or 
6  pounds  in  the  last  two  months.  He  has  always  lived  in  New  Eng- 
land. 

Physical  examination  shows  emaciation,  yellowish  skin,  but  no 
definite  jaundice.  Pupils,  glands,  and  reflexes  negative.  Chest 
negative  save  for  flatness,  diminished  breathing,  diminished  fremitus, 
and  fine  moist  rales  at  the  base  of  each  lung  below  the  angle  of  the 
scapula.  The  abdomen  shows  dulness  in  the  flanks  not  shifting  with 
change  of  position.  In  the  right  lower  quadrant  are  bunches,  prob- 
ably from  a  hernia  in  the  scar  of  the  old  appendix  operation.  The 
Uver  dulness  extends  from  the  sixth  rib  to  a  point  2  cm.  below  the  ribs, 
12  cm.  below  the  ensiform.  Its  smooth,  non-tender  surface  can  be 
indistinctly  made  out.  The  smooth  edge  of  the  spleen  can  also  be 
felt  2  cm.  below  the  ribs  in  the  nipple  Hne.  Later  a  shifting  of  the 
dulness  in  the  flanks  was  demonstrable  on  change  of  position  and  a 


ABDOMINAL  AND    OTHER  TUMORS 


75 


mass  was  made  out  in  the  right  iliac  region.  This  mass  was  about  the 
size  of  half  a  lemon,  egg  shaped,  slightly  irregular  in  surface,  fixed, 
not  tender.  Examination  of  the  urine  and  stools  showed  nothing 
abnormal.  The  blood  was  also  negative.  The  course  of  the  tem- 
perature during  twenty  days'  observation  is  shown  in  the  accompany- 
ing chart  (Fig.  28).  The  patient's  girth  at  the  umbiHcus  was  87  cm. 
before  tapping,  August  loth,  when  2  quarts  of  fluid  were  removed. 
After  this  no  new  masses  were  felt,  but  the  edge  of  the  spleen  and 
the  lump  in  the  right  groin  were  very  distinct  and  there  was  a  visible 
and  palpable  mass  in  the  epigastrium,  probably  part  of  the  liver,  and 
descending  freely  with  respiration.  The  tap  fluid  measured  1850  c.c. 
with  a  specific  gravity  of  1008; 
differential  count:  lympho- 
cytes, 65  per  cent.;  endothehal 
cells,  35  per  cent. 

Dr.  Wilder  Tileston  made  a 
diagnosis  of  hepatic  cirrhosis, 
luetic  or  alcoholic  in  origin, 
with  tuberculosis  of  the  lung. 
The  blood  showed  red  cells, 
1,^00,000;  white  cells,  5000; 
hemoglobin,  40  per  cent. ;  differ- 
ential count,  normal.  Marked 
achromia,  some  stippling  and 
deformity  of  the  red  cells.  No 
nucleated  forms.  August  15th 
a  transfusion  of  blood  was  done, 
after  which  there  was  slight 
icterus  and  the  urine  was  bile 
stained.  The  red  count  rose  to 
2,300,000.  Dr.  Tileston  at  this  time  regarded  the  case  as  Banti's 
disease.     Dr.  C.  A.  Porter  thought  it  was  probably  malignant  disease. 

Discussion. — The  history  gives  us  no  clue,  although  it  suggests 
that  the  trouble  is  probably  abdominal.  The  chest  signs  indicate 
nothing  more  definite  than  a  high  position  of  the  diaphragm.  Despite 
the  opinions  of  the  distinguished  consultant,  who  suggested  cirrhosis 
or  Banti's  disease,  it  seems  to  me  that  attention  should  naturally  be 
concentrated  upon  the  mass  felt  in  the  right  iliac  region.  Neither 
cirrhosis  nor  Banti's  disease  can  account  for  this  mass.  It  is  situated 
in  the  vicinity  of  the  cecum  and  its  association  with  a  continued 
fever  suggests  tuberculosis.     I  do  not  see  how  this  disease  can  be 


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Fig.  28. — Chart  of  Case  17. 


^6  DIFFERENTIAL  DIAGNOSIS 

positively  excluded,  but  the  characteristics  of  the  tap  fluid  are  not  at 
all  those  which  we  would  expect  in  tuberculous  disease  of  the  peri- 
toneum. A  specific  gravity  of  1008  corresponds  rather  with  a  drop- 
sical effusion  or  a  pressure  fluid  than  with  exudate  accompanying 
tuberculosis  of  the  peritoneum. 

Cancer  of  the  cecum  is  also  a  possibility,  but  it  is  not  probable, 
because  we  have  no  symptoms  pointing  distinctly  to  the  intestine, 
no  evidence  of  obstruction,  and  no  diarrhea.  Cancer  of  the  cecum 
usually  remains  for  a  considerable  period  without  forming  extensive 
metastases,  and  the  presence  of  ascites,  which  would  have  to  be  refer- 
able to  such  metastases,  is,  therefore,  somewhat  against  cancer  of  the 
cecum. 

A  lymphoblastoma,  involving  the  spleen,  liver,  and  abdominal 
lymph-glands,  would  seem  to  fit  the  facts  better  than  any  other 
diagnosis.  In  view  of  the  blood  examination,  this  tumor  must  be 
supposed  to  be  of  the  non-leukemic  type,  sometimes  called  Hodgkin's 
disease. 

Outcome. — The  patient  left  the  hospital  August  24th  and  died 
September  14th.  Autopsy  showed  mahgnant  disease  in  the  tail  of 
the  pancreas,  with  extension  to  the  spleen,  very  shght  involvement  of 
the  Hver,  but  considerable  deposits  in  the  retroperitoneal  and  thoracic 
glands. 

Case  18 

A  jeweler  of  thirty-seven  entered  the  hospital  January  i,  191 2. 
The  patient  has  been  well  except  for  children's  diseases  until  five  weeks 
ago,  when  he  lost  his  voice  for  a  few  days  and  felt  so  weak  and  Hstless 
that  he  stayed  in  bed  for  a  week,  coughing  up  much  phlegm  at  that 
time.  He  still  has  a  slight  cough.  Two  years  ago  he  noticed  a  tumor 
in  the  region  of  his  loin  about  the  size  of  a  lemon.  This  tumor  seemed 
to  cause  him  pain  when  he  lay  down  or  sat  for  any  length  of  time. 
He  now  has  a  cluster  of  three  bunches  upon  his  left  forearm  which 
cause  a  drawing  pain  when  he  chops  wood.  Other  similar  bunches 
have  been  noticed  in  various  parts  of  his  anatomy  in  the  past  ten 
years,  but  have  given  no  trouble. 

Physical  examination  is  negative  save  for  moderately  enlarged 
tonsils,  elongated  uvula,  a  chronic  pharyngitis,  and  innumerable 
subcutaneous  tumors  with  which  the  patient's  body  was  almost 
covered.  They  were  firm,  freely  movable,  not  tender,  varying  in  size 
from  that  of  a  walnut  to  that  of  a  duck's  egg.  Both  arms  are  also 
covered  by  these  nodules,  but  there  are  none  upon  the  legs. 


ABDOMINAL  AND   OTHER  TUMORS  77 

Discussion. — When  a  patient  has  had  bunches  in  or  under  his 
skin  in  various  parts  of  his  body  for  ten  years,  without  any  noted 
increase  in  their  size,  we  can  only  suppose  that  a  neurofibroma,  an 
angioma,  or  a  lipoma  is  present.  The  more  malignant  types  of  tumor 
mentioned  in  the  discussion  of  case  No.  ii  can  be  excluded.  So  far 
as  I  am  aware  the  non-leukemic  lymphoblastomata,  while  they  may 
involve  the  skin,  never  last  so  long  as  these  without  producing  more 
marked  S3niiptoms.  Further  evidence  as  to  the  nature  of  these  lumps 
can  only  be  obtained  by  excising  one. 

Outcome. — Three  small  nodules  upon  the  forearm  were  dis- 
sected out  under  ether  anesthesia,  and  another  group  in  the  left  back 
below  the  twelfth  rib,  just  outside  the  erector  spinse  muscles.  Ex- 
amination of  these  tumors  by  Dr.  W.  F.  Whitney  showed  nothing  but 
fat  tissue. 

Case  19 

A  housewife  of  twenty-four  entered  tHe  hospital  August  7,  1909. 
The  patient  has  had  an  uneventful  past  history,  has  one  child,  and 
has  had  no  miscarriages.  Her  menstruation  has  always  been  pain- 
ful. She  has  had  no  regular  period  for  two  months,  but  some  flowing 
for  three  weeks. 

Three  weeks  ago,  while  ironing,  she  felt  as  if  something  suddenly 
slipped  down  in  the  pelvis,  and  immediately  felt  sharp  pain  there 
and  down  the  left  leg.  She  felt  faint  and  lay  down,  with  much  reHef . 
Since  then  she  has  not  been  free  from  pain,  though  it  has  usually  been 
only  a  dull  ache.  At  times,  however,  it  has  been  so  sharp  as  to  awake 
her  from  sleep  or  to  cause  vomiting.  These  attacks  are  relieved  by 
morphin.  Of  late  she  has  several  times  felt  chilly  or  feverish.  Her 
appetite  is  good,  bowels  loose;  she  sleeps  only  with  drugs. 

Physical  examination  shows  good  nutrition  and  color.  Pupils, 
glands,  and  reflexes  normal.  Abdomen  negative  except  as  shown  in 
Fig.  29.  White  corpuscles,  13,400;  hemoglobin,  85  per  cent.  Urine 
negative.    Temperature,  99.5"  F.  at  entrance.    Pulse,  80. 

Discussion. — The  essential  points  in  this  case  are  the  irregularity 
of  menstruation,  the  sudden  onset  of  pelvic  pain  and  presence  of 
pelvic  tumor,  without  signs  of  peritoneal  inflammation.  The  two 
pelvic  diseases  which  most  often  begin  suddenly  and  present  a  tumor 
on  examination  are  extra-uterine  pregnancy  and  the  torsion  in  the 
pedicle  of  an  ovarian  cyst.  Pyosalpinx  may,  of  course,  begin  sud- 
denly, yet  not,  as  a  rule,  so  suddenly  as  in  the  present  case.  The 
amount  of  tenderness  and  fever  is  usually  greater  in  salpingitis  than 


78 


DIFFERENTIAL  DIAGNOSIS 


in  the  present  case.  It  is  notable  that  the  patient  has  good  color  and 
a  normal  hemoglobin.  Were  there  any  extensive  hemorrhage  or 
peritonitis,  the  color  and  hemoglobin  would  probably  be  poor. 

Since  menstrual  irregularities  are  somewhat  more  often  asso- 
ciated with  extra-uterine  pregnancy  than  with  ovarian  cyst,  the  latter 
diagnosis  seems  less  probable  in  this  case. 

Outcome. — Operation,  August  gth,  showed  a  large  blood-stained 
mass  in  the  left  tube.     The  left  tube  and  ovary  were  removed,  also 


Fig.  29. — The  dotted  outline  shows  the  dull  area. 

tender. 


The  area  labeled  a  was  resistant  and 


the  appendix.  Pathologic  examination  showed  a  mass  the  size  of  an 
orange,  made  up  of  a  thickened  tube,  much  blood-clot,  and  the  ovary. 
Microscopic  examination  shows  thickening  of  the  walls  of  the  tube 
with  engorgement  of  the  vessels  and  some  inflammatory  reaction,, 
also  a  few  structures  suggesting  villi,  but  no  positive  signs  of  preg- 
nancy. Nevertheless  the  case  was  considered  one  of  extra-uterine 
pregnancy.  The  patient  made  an  uneventful  recovery  and  left 
the  hospital  on  the  23d  of  August. 


ABDOMINAL  AND    OTHER   TUMORS  79 


Case  20 


An  unmarried  girl  of  twenty-five  was  sent  into  the  surgical  wards 
with  an  Out-patient  Department  diagnosis  of  "sarcoma  of  the  thigh," 
November  3,  191 1.  The  patient  had  never  been  sick  before,  but  had 
a  cataract  removed  from  the  right  eye  a  year  ago  at  the  Carney  Hospi- 
tal. At  that  time  she  had  enlarged  glands  in  the  groins  and  first 
noticed  contractions  of  the  cords  behind  the  knee.  The  inguinal 
glands  have  grown  steadily,  but  have  not  been  severely  painful, 
though  the  discomfort  from  them  has  sometimes  kept  her  awake. 
For  a  month  she  has  not  worked.  She  has  lost  in  the  past  year  15 
pounds  in  weight. 

Physical  examination  shows  good  nutrition.  The  pupil  of  the  left 
eye  showed  an '  irregularity  corresponding  to  the  operation  above 
referred  to.  The  other  pupil  normal.  Mouth  and  glandular  struc- 
tures negative.  Chest  and  abdomen  negative.  Over  the  left  thigh, 
beginning  just  below  the  groin  and  extending  down  the  anterior  and 
internal  surface  about  14  cm.,  is  a  tender  swelling,  not  coimected  with 
the  superficial  tissues,  not  fluctuant,  and  apparently  beneath  the 
superficial  muscles.     An  x-ray  showed  no  involvement  of  the  bone. 

Discussion. — The  tumor  in  this  case  occupies  an  unusual  position. 
One  sees  in  this  situation  a  glandular  mass  extending  downward  from 
the  inguinal  lymph-chain,  thrombosed  veins,  inflammatory  exudates 
originating  in  an  osteomyelitis  of  the  femur,  and  malignant  tumors 
springing  from  the  same  bone.  The  latter,  however,  would  present 
a  much  larger,  more  diffuse  growth.  Lymphoblastoma,  involving  the 
inguinal  glands,  would  probably  appear  elsewhere,  and  is  rarely  so 
tender.  Such  glandular  masses  would  be  very  unKkely  to  seem  so 
deeply  situated  beneath  the  superficial  muscles. 

A  phlebitis  should  show  involvement  of  the  vein  above  and  below 
the  point  described  in  this  case.  It  would  hardly  be  possible  for  a 
phlebitis  to  be  confined  to  a  space  14  cm.  in  length. 

Since  the  x-ray  shows  no  involvement  of  the  bone,  it  is  not  likely 
that  we  are  dealing  with  an  exudate  springing  from  an  osteomyelitis. 

Herewith  I  have  excluded  all  the  possibilities  suggested  in  the 
first  place,  and  must  confess  that  I  was  at  a  loss  to  make  a  diagnosis, 
and  was  quite  unprepared  for  the  lesions  shown  in  the  outcome. 

Outcome. — Operation  on  the  loth  of  November  showed  a  mass 
involving  the  muscle  tissue  and  not  incapsulated.  The  tissue  was 
white  and  fibrous,  strongly  suggesting  sarcoma.  A  piece  the  size  of 
the  palm  of  the  hand  was  removed.     Examination  by  Dr.  W.  F. 


8o 


DIFFERENTIAL   DL\GNOSIS 


Whitney  showed  dense  fibrous  tissue,  in  the  midst  of  which  there 
were  irregular  areas  of  cheesy  material.  On  the  edge  of  this  cheesy 
degeneration  were  lines  of  round-cell  infiltration  and  in  the  adjacent 
tissue  small  vessels  with  marked  proHferation  of  the  intima.  In  one 
of  these  vessels  a  shghtly  cellular  nodule,  lying  just  beneath  the 
intima.  In  several  places  there  were  large  scattered  giant-cells. 
Diagnosis,  gumma.  Wassermann  reaction  positive;  0.6  gm.  of  "606" 
was  given  intravenously,  and  iodid  of  potash,  5  to  30  gr.,  three  times  a 
day.  The  patient  left  the  hospital  on  November  29,  191 1.  Decem- 
ber 6   191 2,  she  was  seen  and  was  apparently  in  perfect  health. 

Case  21 

A  colored  boy  of  fifteen,  employed  in  a  shoe  factory,  entered  the 
hospital  January  19,  1910.  The  patient's  family  history  and  past 
history  were  negative  until  last  May,  when  his  abdomen  got  large 


Fig.  30. — Mass  felt  in  Case  21,  January,  1910. 

and  tight;  on  the  19th  it  was  opened  and  much  fluid  removed,  with 
great  relief.  He  then  remained  well  all  summer  and  up  to  a  month 
ago,  when  he  began  to  have  pain  in  the  region  of  the  scar  and  to  the 
right  of  it.  This  pain  was  always  worse  at  night,  especially  after  a  heavy 
supper.  It  usually  came  about  three  hours  after  eating  and  lasted 
four  or  five  hours.      His  appetite  and  digestion  were  good,  bowels 


ABDOMINAL  AND    OTHER  TUMORS 


8l 


regular.  He  had  no  cough  until  within  the  past  two  days.  For 
three  weeks  he  has  been  much  troubled  by  itching  all  over  his  trunk- 
Physical  examination  showed  fair  nutrition.  At  the  right  pul- 
monary apex  behind  there  were  fine  crackles,  with  cough,  and  over 
the  left  clavicle  the  breathing  was  abnormally  high  pitched.  The 
heart  was  normal.  The  abdomen  was  slightly  full  and  spastic,  espe- 
cially in  the  right  half,  where  there  was  an  indefinite  mass,  as  shown 
in  the  accompanying  diagrams  (Figs.  30,  31,32).  The  temperature  as 
in  the  accompanying  chart  (Fig.  33).     During  his  two  months'  stay 


Fig.  31. — Chest  signs  in  Case  21,  January,  19 10. 

in  the  hospital  he  slowly  lost  weight.  At  entrance  it  was  1 1 1^  pounds ; 
at  discharge,  104  pounds.  He  was  perfectly  comfortable,  as  a  rule, 
but  unless  his  bowels  were  kept  very  free  he  had  attacks  of  sharp  pain 
in  the  right  lower  quadrant,  relieved  by  glycerin  enema.  He  did  not 
improve  in  any  respect  and  was  sent,  on  the  17th  of  March,  to  the 
Lakeville  Sanitarium.     His  itching  was  due  to  scabies. 

He  entered  the  Massachusetts  General  Hospital  again  July  5, 
1910,  coming  there  straight  from  the  sanitarium,  where  he  had  gained 
6  pounds  and  for  two  months  had  less  pain.     The  condition  of  his 

Vol.  II— 6 


82 


DIFFERENTIAL  DIAGNOSIS 


abdomen  is  shown  in  Fig.  34.  In  other  respects  he  was  practically 
as  before.  Operation  was  advised,  and  in  view  of  the  lower  tempera- 
ture (Fig.  35)  and  the  negative  blood  and  urine,  he  was  transferred 
to  the  surgical  wards. 

Discussion. — In  view  of  the  soundness  of  the  heart  and  kidney 
in  this  case,  one  can  scarcely  consider  with  seriousness  any  diagnosis 
except  tuberculous  peritonitis.  This  is  by  far  the  commonest  cause 
of  free  fluid  in  the  abdomen  in  a  boy  of  fourteen.  Malignant  disease, 
especially  lymphoblastoma,  is  possible,  but  rare. 


Fig.  32. — Chest  signs  in  Case  21,  January,  19 10. 

At  the  time  of  his  second  entry,  when  a  tumor  was  present,  there 
could  no  longer  be  any  question  of  any  diagnosis  except  the  two 
already  mentioned,  and  the  duration  of  the  illness,  together  with 
the  existence  of  fever,  makes  tumor  very  improbable.  The  fact  that 
there  has  been  a  gain  in  weight  and  improvement  in  the  general 
condition  makes  it  practically  certain  that  he  is  not  suffering  from 
malignant  disease. 

Outcome. — On  the  19th  of  July  the  abdomen  was  opened  with 
some  difficulty,  owing  to  adhesions  between  the  intestines  and  the 
abdominal  wall.     The  tumor  proved  to  be  a  mass  of  large  and  small 


ABDOMINAL  AND    OTHER   TUMORS 


83 


intestines   matted    together   about   the    cecum.     Numerous   miliary 
tubercles  were  scattered  over  the  intestine  and  on  the  parietal  peri- 
toneum.    The  remainder  of  the  peritoneal  cavity  was  not  explored 
owing  to  numerous  adhesions.     The  boy  recovered  well  from  the 


operation,  but  continued  to  run  a  temperature  between  100°  and 
101°  F.  until  his  discharge,  August  ist. 

The  patient  was  seen  February  19,  19 13.     He  was  then  at  work, 
eating  ravenously,  sleeping  well,  and  free  from  fever.     His  bowels 


84 


DIFFERENTIAL  DLA.GNOSIS 


moved  three  or  four  times  daily  and  the  movements  were  rarely  solid. 
When  he  left  the  hospital   he   weighed  104  pounds;  at  this  time  he 


Fig.  34. — Signs  in  Case  21,  July  5,  1910 


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Fig.  35. — Chart  II  of  Case  21. 

weighed  120  pounds.     There  was  still  a  fistulous  opening  at  the  site 
of  the  last  operation. 


ABDOMINAL  AND   OTHER  TUMORS  85 

Case  22 

A  farmer  of  fifty-seven  entered  the  hospital  January  28,  19 10. 
The  patient's  mother  died  of  tuberculosis,  otherwise  his  family  history 
is  good.  He  has  had  indigestion  for  ten  years,  beginning  sixteen  years 
ago  and  ending  six  years  ago.  He  denies  venereal  disease  and  has 
good  habits. 

Six  months  ago  he  began  to  notice  soreness  in  the  right  lower 
quadrant  of  the  abdomen,  with  occasional  attacks  of  dyspepsia,  and 
soon  after  this  he  felt  a  mass  in  the  region  of  the  soreness.  He  thinks 
it  has  grown  slightly  since  that  time.  Three  weeks  ago  he  lost  his 
appetite  and  for  three  days  vomited  almost  everything  and  had 
more  pain  than  usual.  The  vomiting  grew  less  and  ceased  four  days 
ago,  since  when  he  has  felt  comfortable,  though  weak.  Bowels 
slightly  irregular,  but  he  now  eats  and  sleeps  fairly  well.  Last  spring 
he  weighed  165  pounds,  with  clothes;  September  6th,  151  pounds,  with 
clothes;  now  129  pounds,  without  clothes.  He  stopped  work  three 
weeks  ago.  For  some  time  he  has  had  attacks  of  sharp  pain,  last- 
ing two  or  three  minutes,  after  meals,  and  accompanied  sometimes  by 
rumbling  noises,  sometimes  brought  on  by  pressure  upon  the  abdomen. 
For  the  last  three  weeks  he  has  needed  laxatives  to  make  his  bowels 
move. 

Physical  examination  shows  fair  nutrition,  considerable  sallow 
pallor,  though  his  hemoglobin  reads  90  per  cent,  and  the  stained  smear 
is  normal.  Pupils,  glands,  and  reflexes  normal.  Chest  normal.  In 
the  right  lower  quadrant  is  a  hard,  nodular  mass,  sKghtly  tender  and 
movable  on  palpation.  In  the  flank  peristalsis  is  visible  near  it 
(Fig.  36).  Blood  and  urine  negative.  Temperature  normal  for  a 
week. 

Discussion. — A  mass  in  the  region  of  the  cecum,  coming  on  at 
the  age  of  fifty-seven,  with  disturbances  of  intestinal  function,  is 
strong  presumptive  evidence  of  malignant  disease  of  the  large  intes- 
tine. In  a  younger  person  tuberculosis  might  produce  the  same 
symptoms,  although  the  intestinal  symptoms  of  pericecal  tubercu- 
losis are  rarely  as  marked  as  in  this  case.  A  renal  tumor  might  show 
itself  in  this  part  of  the  abdomen,  but  would  hardly  be  associated 
with  such  marked  intestinal  symptoms  as  this  patient  presents. 

Regarding  the  variety  of  neoplasm,  we  have  only  to  distinguish 
between  carcinoma  (epithelioblastoma)  and  malignant  l3anphoma 
(lymphoblastoma).  The  latter  tumor,  which  is  ordinarily  called 
sarcoma  when  met  with  in  this  site,  is  much  less  common  than  the 


86 


DIFFERENTIAL  DLA.GNOSIS 


former  in  a  patient  of  fifty-seven.     On  the  whole,  I  think  the  diag- 
nosis of  cancer  of  the  cecum  is  satisfactorily  clear. 

Outcome. — On  the  5th  of  February  the  patient's  abdomen  was 
opened.  A  considerable  amount  of  clear,  dark  yellow  fluid  escaped. 
At  the  ileocecal  valve  a  large,  firm,  freely  movable  mass  was  found, 
with  extensions  running  down  into  the  pelvis  and  up  toward  the  liver. 
Several  loops  of  intestine  were  adherent  to  it.     A  bit  was  excised 


■MoSulcr, 

ten  6er, 

i-mo  vable 
Hot  ftb- 
\n  the 


Fig.  36. — ^Slass  felt  in  Case  22. 

for  diagnosis  and  the  abdomen  then  closed.     Microscopic  examina- 
tion by  Dr.  J.  H.  Wright  showed  adenocarcinoma. 

The  patient  left  the  hospital  February  15,  19 10,  and  gradually 
failed  at  his  home,  dying  March  26th.  During  the  last  months  of  his 
Hfe  he  lived  almost  entirely  on  buttermilk. 

Case  23 

A  maid  of  thirty  entered  the  hospital  April  4,  19 10.  For  many 
years  the  patient  has  noticed  tender  swelHngs  over  the  left  clavicle  and 
on  the  forehead.  Four  weeks  ago  she  began  to  have  headaches. 
Two  weeks  ago  she  began  to  get  hoarse.     For  five  days  she  has  had 


ABDOMINAL  AND    OTHER  TUMORS  87 

rapidly  increasing  dyspnea,  otherwise  she  has  had  no  respiratory 
symptoms.  Her  husband  has  had  consumption  for  two  years.  Her 
family  history  and  past  history  are  negative.  She  has  six  healthy 
children.  She  is  now  nursing  a  healthy  five  months'  baby.  Eleven 
years  ago  she  had  a  miscarriage  at  eight  months.  She  has  had  four 
healthy  children  since. 

Physical  examination  shows  good  nutrition.  The  right  pupil  is 
slightly  irregular  and  is  larger  than  the  left.  Both  react  normally. 
No  glandular  enlargement.  Chest,  abdomen,  and  reflexes  negative. 
On  each  frontal  eminence  is  a  tumor  about  2  cm.  in  diameter.  On  the 
left  clavicle  is  a  similar  rounded  enlargement,  and  on  the  external 
condyle  of  the  left  humerus  is  a  swelHng  the  size  of  an  English  wahiut, 
somewhat  tender.  On  the  left  leg,  below  and  outside  the  knee-cap, 
is  a  fluctuant  tnass  5  cm.  in  diameter.  In  the  middle  of  the  left  tibia 
is  a  deep  dry  ulcer  |  cm.  in  diameter.  There  is  forward  bowing  of  the 
right  tibia  8  cm.  below  the  knee  pan  and  the  lower  portion  of  this 
tibia  is  much  thickened  laterally. 

The  patient  was  greatly  troubled  by  dyspnea  at  entrance  and 
showed  evidence  of  laryngeal  stenosis.  The  Wassermann  reaction 
was  positive.  Otherwise  the  blood  was  normal.  Ten  examinations 
of  sputa  for  tubercle  bacilli  were  negative,  as  were  the  feces.  There 
was  no  fever. 

Discussion. — Here  we  are  dealing  with  a  case  presenting  multiple 
fluctuant  lumps.  Among  the  possibiHties  are  wens,  fatty  tumors, 
abscesses  due  to  pyogenic  cocci,  glanders,  tuberculosis,  syphiHs,  neo- 
plasm, and,  as  bare  possibilities,  coccidioidal  granuloma,  blasto- 
mycosis, and  actinomycosis. 

If  we  are  to  make  one  diagnosis  covering  all  the  functional  dis- 
turbances present  in  this  patient,  we  can  exclude  at  once  wens,  lipomata, 
glanders,  and  pyogenic  abscesses,  as  those  cannot  well  be  a  part  of  any 
general  pathologic  process  which  produces  hoarseness,  bony  lesions, 
and  dyspnea.  Tuberculosis,  syphiUs,  and  the  other  lesions  men- 
tioned might  account  for  all  the  other  symptoms.  The  family  history 
of  tuberculosis  makes  that  especially  deserving  of  consideration,  but 
the  site  of  the  lesions,  especially  their  presence  on  the  clavicles  and 
the  changes  in  the  tibiae,  are  not  at  all  characteristic  of  tuberculosis. 
Moreover,  a  tuberculosis  which  has  produced  so  many  external  lesions 
is  likely  to  have  involved  the  lungs  by  this  time.  Against  malignant 
disease  are  the  patient's  age  and  the  involvement  of  the  bones.  Against 
syphilis  we  have  nothing  except  the  fact  that  the  patient  has  six  healthy 
children,  and  that  fact,  on  the  whole,  is  a  much  less  important  one 


88 


DIFFERENTIAL  DIAGNOSIS 


than  those  which  have  been  mentioned  as  militating  against  the 
other  diagnoses  previously  discussed.  On  the  whole,  syphilis  seems 
the  most  probable  diagnosis.  Coccidioidal  granuloma,  blastomyco- 
sis, and  actinomycosis  can  only  be  excluded  by  a  careful  examination 
of  the  discharge  from  the  lesions,  but  they  are  all  very  improbable. 

Outcome. — Under  mercurial  inunctions  and  potassium  iodid  the 
dyspnea  rapidly  improved,  but  on  the  4th  of  April  again  became  so 
distressing  that  tracheotomy  was  considered.  After  April  5th  the 
dyspnea  steadily  improved  and  by  the  14th  was  almost  gone.  The 
patient  went  home  on  the  19th,  much  reheved. 

Case  24 

A  tailor  of  thirty-seven,  born  in  Russia,  entered  the  hospital 
March  2,  19 10.     The  patient  complained  chiefly  of  pain  in  the  left 

hypochondrium,  with  loss  of 
appetite  and  fatigue  on  slight 
exertion.  The  pain  was  worse 
after  meals,  and  especially  bad 
at  night,  when  it  often  woke 
him  up.  In  the  past  six  months 
he  has  lost  24  pounds  and  much 
strength.  Since  he  was  a  boy 
he  has  been  in  the  habit  of  pass- 
ing urine  one  to  four  times  in 
the  night.  Since  February  5th 
he  has  been  unable  to  work  and 
has  been  in  bed.  Two  weeks 
ago  his  physician  noticed  a 
mass  in  the  left  upper  quadrant. 
For  as  long  as  he  can  re- 
member he  has  taken  three 
whiskies  and  three  beers  a 
day,  but  has  had  no  previous 
He  has  three  children  living  and 


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Fig.  37. — Chart  I  of  Case  24. 


illness.    His  family  history  is  good. 
well.     His  wife  has  had  no  miscarriage. 

On  the  patient's  entrance  to  the  hospital  his  temperature  was 
101.2°  F.,  which  rose  the  next  morning  to  103°  F  (Fig.  37).  His 
nutrition  was  good,  but  he  showed  distinct  pallor.  Under  each 
ear,  between  the  mastoid  process  and  the  jaw-bone,  was  a  smooth, 
tender  gland.  A  few  other  flattened  glands  were  felt  in  the  left 
axilla.     In  both  groins  glands  the  size  of  large  beans  were  felt.     The 


ABDOMINAL  AND   OTHER   TUMORS 


89 


heart's  apex  extended  2  cm.  outside  the  nipple  line  by  percussion,  but 
was  never  seen  nor  felt.  Right  border  of  dulness  2  cm.  from  midster- 
num.  Pulmonic  second  sound  seemed  somewhat  accentuated  and 
there  was  a  very  soft  systolic  murmur  at  the  apex.  The  lungs  were 
normal.  A  rounded  edge,  apparently  belonging  to  the  spleen,  was 
felt  7  cm.  below  the  left  ribs  and  could  be  traced  into  the  flank.  Per- 
cussion dulness  extended  up  under  the  ribs  so  that  the  vertical  diameter 
of  the  organ  was  in  the  vicinity  of  17  cm.  Its  horizontal  diameter 
was  25  cm.  The  red  cells  numbered  3,450,000;  white  cells,  10,700; 
hemoglobin,  75  per  cent.  Of  the  leukocytes,  38  per  cent,  were  poly- 
nuclears,  44  per  cent,  large  lymphocytes  and  transitional  cells,  18 
per  cent,  small  lymphocytes. 


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Fig.  38. — Chart  II  of  Case  24. 


On  the  3d  of  March  I  noted  that  the  mass  in  the  splenic  region 
was  deeper  and  more  rounded  than  is  the  rule  when  one  palpates  a 
large  spleen.  The  glandular  enlargement  seemed  to  me  demon- 
strable only  in  the  groins.  The  blood-platelets  numbered  122,000. 
The  patient  complained  of  pain  in  the  region  of  the  spleen.  The 
urine  averaged  30  ounces  in  twenty-four  hours,  with  a  specific  gra^dty 
in  the  neighborhood  of  1014.  The  sediment  contained  a  small 
amount  of  pus  on  every  examination.  By  the  9th  of  March  the  poly- 
nuclear  cells  had  risen  to  48  per  cent.;  lymphocytes  were  47.9  per  cent., 
40  per  cent,  being  of  the  large  type;  eosinophils  made  up  the  remainder. 


90 


DIFFERENTLVL  DL\GNOSIS 


The  blood-platelets  were  209,000.  A  swathe  entirely  relieved  the 
complaint  of  pain  in  the  region  of  the  spleen.  No  medication  except 
laxatives  was  given. 

He  left  the  hospital  on  the  12th  of  March  and  did  not  re-enter 
until  a  year  later,  February  13th;  he  said  that  he  had  done  well  all 
through  the  summer  and  autumn;  three  months  ago  he  began  to 
have  chills  followed  by  headaches,  but,  so  far  as  he  knows,  by  no 
fever.  He  sweats  freely  each  night  and  sleeps  poorly.  He  thinks 
his  spleen  is  growing  larger.     It  hurts  him  to  He  on  the  left  side. 


Fig.  39.-^Spleen  in  Case  24. 

He  has  done  no  work  for  fifteen  months  and  has  been  in  bed  for  three 
months.  Fifteen  months  ago  he  weighed  165  pounds.  He  lost  a 
good  deal  of  weight  during  the  time  of  his  previous  stay  in  the  hospital; 
next  he  gained  22  pounds  during  last  summer,  but  has  lost  rapidly  in 
the  last  three  months.  His  weight,  without  clothes,  February  15, 
191 1,  was  102^  pounds. 

Nevertheless,  he  was  now  fairly  nourished  and  did  not  look  sick. 
His  pupils  were  normal.  The  cervical  lymph-nodes  were  not  enlarged. 
In  the  right  axilla  there  was  a  gland  the  size  of  an  almond.    The 


ABDOMINAL  AND    OTHER  TUMORS 


91 


inguinals  were  as  large  as  beans.  The  condition  of  the  spleen  was  as 
shown  in  Fig.  39,  and  did  not  appear  to  exceed  that  previously  meas- 
ured. The  heart  showed  the  same  lesions  previously  noted.  The 
knee-jerks  were  both  reduced;  in  fact,  they  were  present  only  on  re- 
inforcement. There  was  no  edema.  During  the  two  months  of 
this  his  second  stay  in  the  hospital  his  red  corpuscles  remained  in  the 
vicinity  of  3,000,000,  though  they  gained  slightly  in  the  last  two  weeks. 
His  hemoglobin  rose  from  60  to  85  per  cent.  The  course  of  his  white 
corpuscles  is  seen  in  Fig.  40. 
The  red  cells  showed  marked 
achromia  with  some  abnormal 
staining  and  stippling,  also  con- 
siderable variations  in  size  and 
shape.  About '20  per  cent,  of 
the  l3niiphocytes  were  of  the 
small  type,  the  rest  large.  The 
patient  had  x-isiy  treatment 
every  other  day  and  improved 
very  markedly.  His  tempera- 
ture was  elevated  for  the  first 
two  weeks  and  a  half.  After 
that  it  was  normal.  Systolic 
blood-pressure,  no  mm.  Hg. 
The  urine,  as  before,  showed 
considerable  pus  in  the  sedi- 
ment, but  20  minims  of  this  sediment  injected  into  a  guinea-pig 
produced  no  results.     The  Wassermann  reaction  was  unsatisfactory. 

Discussion. — The  essentials  of  this  case  are  a  dyspepsia  of  long 
duration  in  an  alcoholic  patient,  associated  with  emaciation  and  an 
apparently  habitual  nocturia.  The  physical  examination  shows  espe- 
cially a  mass  in  the  left  hypochondrium  strongly  suggesting  the 
spleen,  a  general  glandular  enlargement,  and  a  curious  blood-picture, 
involving  an  increase  of  lymphocytes. 

There  can  be  Uttle  doubt,  I  think,  that  the  tumor  is  a  spleen. 
The  blood-picture  is  not  precisely  characteristic  of  any  known  disease. 
It  is  most  suggestive  of  a  transition  from  a  non-leukemic  to  a  leukemic 
form  of  lymphoblastoma.  The  case  is  a  most  interesting  one,  be- 
cause just  this  transition  is  very  rarely  observed.  Despite  all  that 
has  been  written  by  Bunting,  Lazarus,  and  others,  we  have  today  no 
characteristic  blood-picture  for  the  greater  part  of  the  duration  of  the 
•disease  formerly  known  as  Hodgkin's  disease,  and  now  more  generally 


30  000 
25  000 

n 

T 

Dtc 

lI 

L 

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es 

— 

20  000 

^ 

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15  000 

\ 

\ 

1 0  000 

\ 

S  000 

V 

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r* 

90% 

L 

ym 

ph 

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tes 

80% 

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s 

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t 

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si\ 

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6 

N 

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tar 

s 

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- 

Fig.  40. — Chart  of  white  corpuscles  of  Case  24. 


92  DIFFERENTIAL   DIAGNOSIS 

known  as  malignant  lymphoma  or  lymphoblastoma.  The  lympho- 
cytic increase  described  by  the  writers  just  mentioned  is  not  always 
present  and  the  blood  is  often  essentially  normal.  In  the  present 
case  there  is  certainly  an  increase  in  the  number  of  lymphocytes  and 
especially  in  the  larger  varieties.  This  increase  is  hardly  enough  to 
deserve  the  name  of  leukemia,  but  might  be  called  subleukemic. 
Without  much  doubt  the  typical  leukemic  blood-picture  will  appear 
later. 

Outcome. — He  left  the  hospital  on  the  21st  of  March,  promising 
to  report  at  the  Out-patient  Department. 

The  patient  was  seen  in  February,  19 13,  and  said  he  was  getting 
on  very  fairly.  He  had  some  trouble  with  headache  and  pain  in  the 
splenic  region  and  was  unable  to  work,  but  when  at  rest  had  no  con- 
siderable discomforts.  The  blood  showed  practically  the  same 
picture  as  when  last  examined. 

Case  25 

A  stationary  engineer,  a  Swede,  of  forty,  entered  the  hospital 
March  26,  1910.  The  patient's  family  history  is  good.  He  had  a 
chancre  without  other  symptoms  seventeen  years  ago.  His  habits 
are  good.  Two  years  ago  he  had  a  slight  swelling  to  the  left  of  his 
breast  bone.  It  varied  a  good  deal  in  size,  appearing  and  disappear- 
ing, first  on  one  side  and  then  on  the  other  side  of  the  breast  bone. 
Nevertheless,  he  has  considered  himself  well  and  has  done  his  usual 
work  until  last  December.  During  that  month  he  was  examined  at 
the  Boston  Dispensary  and  states  that  nothing  abnormal  was  found. 
Since  that  time  the  tumor  near  the  breast  bone  has  appeared  again. 
He  has  had  no  severe  pain  anywhere  except  nagging  discomfort  in 
both  arms  and  shoulders,  not  associated  with  exertion.  For  over  a 
year  he  has  noticed  some  shortness  of  breath  on  severe  exertion. 
Otherwise  he  has  had  no  symptoms. 

Physical  examination  showed  that  the  left  pupil  was  larger  than 
the  right.  The  heart's  apex  extended  2  cm.  outside  the  nipple  line,  the 
right  border  5  cm.  from  midsternal  line.  The  sounds  were  rather 
muffled  and  there  was  a  soft  systolic  murmur  at  the  apex,  not  transmit- 
ted. Aortic  second  slightly  accentuated.  Systolic  blood-pressure,  145 
mm.  Hg.  Over  the  upper  part  of  the  sternum  and  to  the  right  of  it  was 
a  conical  swelling  the  size  of  half  a  lemon,  tense,  elastic,  and  pulsating 
in  all  directions.  A  diastolic  shock  was  clearly  felt  over  it.  The  right 
pulse  was  barely  palpable ;  the  left,  of  good  volume,  slightly  increased 
tension.  Both  were  regular.  The  blood-pressure  tested  in  the  left  radial 


ABDOMINAL  AND   OTHER   TUMORS  93 

was  30  points  higher  than  in  the  right.  This  discrepancy  slightly  dimin- 
ished in  the  next  month  and  markedly  in  the  succeeding  month,  so 
that  at  the  time  of  his  discharge,  May  15th,  the  two  pressures  were 
practically  identical.  Between  the  spine  of  the  right  scapula  and  the 
median  line  was  an  area  the  size  of  the  palm  where  bronchovesicular 
breathing  and  egophony  were  made  out,  but  there  was  no  dulness 
there.  There  was  at  no  time  any  thrill  or  murmur  over  the  mass  near 
the  sternum,  and  the  absence  of  pain  was  quite  striking. 

Discussion. — Aneurysm  or  mediastinal  tumor  are  practically  the 
only  conditions  which  deserve  consideration  here.  Tuberculosis  is 
altogether  improbable.  Against  aneurysm  is  the  absence  of  all  pain 
and  the  absence  of  any  palpable  thrill  or  audible  murmur.  The  two 
last  signs,  however,  are  not  infrequently  wanting  in  aneurysm. 

In  favor  of  aneurysm  are  the  presence  of  a  syphilitic  history,  the 
condition  of  the  pupils,  and  the  definite  pulsation  palpable  over  the 
tumor.  All  of  these  conditions  might  coexist  with  a  neoplasm,  but 
such  a  coincidence  is  improbable. 

Outcome. — Hypernephroma  with  metastasis  was  considered,  al- 
though the  blood  and  urine  were  normal.  At  times  the  right  hand 
was  colder  than  the  left.  The  Wassermann  reaction  was  positive.  On 
the  6th  of  April  the  tumor  was  about  half  the  size  it  had  been  at 
entrance.  Potassium  iodid,  20  gr.  three  times  a  day,  had  been  given 
in  the  interval,  together  with  mercurial  inunctions.  Operation  was 
advised,  but  refused;  x-ray,  taken  at  entrance,  showed  a  shadow 
14I  cm.  in  diameter,  and  on  the  30th  of  April  there  was  no  change  in 
this  shadow.  Later  the  aneurysmal  tumor  increased  to  its  former  size 
and  remained  there  until  the  time  of  his  discharge.  May  i6th. 

The  patient  died  at  his  home  March  10,  191 2.  During  the  last 
six  months  of  his  Hfe  he  was  subject  to  spells  of  choking,  and  it  was  in 
one  of  these  spells  that  he  died  very  suddenly. 

Case  26 

An  ironworker  of  thirty- three  entered  the  hospital  August  25, 
1910.  Two  or  three  years  ago  the  patient  first  noticed  a  hard  mass 
in  the  left  hypochondrium.  It  has  grown  steadily  since,  and  in  the  last 
year  he  has  lost  15  pounds.  It  is  only  in  the  last  six  months,  however, 
that  he  has  felt  a  gradually  increasing  fatigue  at  his  work  as  an  iron 
molder.  His  appetite  and  sleep  are  good,  his  bowels  regular,  and, 
save  for  weakness,  he  still  feels  well. 

Nine  years  ago  he  had  a  chancre  and  took  "blood  medicine"  for  a 
year  thereafter  under  the  advice  of  a  druggist.     He  had  no  skin  erup- 


94 


DIFFERENTIAL  DL\GNOSIS 


tion  or  sore  throat.  Four  years  ago  he  was  married  and  has  two 
healthy  children.  His  v/ife  has  had  no  miscarriage.  His  habits  are 
good.     He  has  lived  in  New  England  practically  his  whole  hfe. 

Physical  examination  shows  good  nutrition,  pupils  slightly  non- 
circular,  but  reacting  normally.  Lymph-nodes  somewhat  enlarged  in 
the  axillae,  groins,  and  epitrochlear  region,  not  in  the  neck.  At  the 
angle  of  the  right  jaw  is  a  pigmented  scar,  3  by  5  cm.  There  is 
visible  lateral  pulsation  in  the  brachial  arteries  and  the  arterial  walls 
are  palpable  between  beats.     The  chest  is  negative.     The  belly  is 


Fig.  41. — Mass  felt  in  Case  26. 

negative,  except  that  in  the  left  hypochondrium  there  is  a  firm,  non- 
tender  mass  with  a  sharp  edge,  descending  with  respiration,  easily 
felt  bimanually,  not  traversed  by  the  inflated  colon  (Fig.  41). 
There  is  a  scar,  with  evidence  of  loss  of  substance,  on  the  frenum. 
The  right  shin  is  much  bowed  and  thickened  in  the  upper  half,  but 
smooth. 

Banti's  disease,  splenic  anemia,  S3^hilis,  and  leukemia  were  consid- 
ered, but  the  blood  showed  no  evidence  of  the  latter  disease,  the  white 
cells  numbering  3600  with  56  per  cent,  of  polynuclears,  i  per  cent. 


ABDOMINAL  AND    OTHER   TUMORS  95 

eosinophils,  and  the  rest  lymphocytes.  Red  cells  numbered  4,000,000, 
hemoglobin  70  per  cent.,  no  nucleated  forms.  The  stools  showed  no 
reaction  to  guaiac.  Urine  negative.  Weight,  141  pounds  at  en- 
trance; 146  pounds  at  discharge,  two  weeks  later.  The  temperature 
was  occasionally  elevated  in  the  afternoon,  once  to  99.5°  F.,  once 
to  100.5°  F.  As  a  rule  it  was  normal.  Daily  jc-ray  treatment  to  the 
spleen  had  no  considerable  effect  upon  its  size.  On  the  ist  of  Sep- 
tember a  high-pitched  inspiration  and  a  few  crackling  rales  were 
heard  below  the  right  clavicle,  and  in  the  right  back,  near  the  angle 
of  the  scapula,  inspiration  was  also  somewhat  high  pitched.  The 
fundus  oculi  was  normal. 

Discussion. — In  summary,  this  patient  presents  an  enlarged 
spleen,  a  general  glandular  enlargement,  a  scar  on  the  frenum,  a  slight 
degree  of  secondary  anemia,  and  a  thickening  of  the  right  shin-bone. 
Syphilis  is  the  only  disease  that  easily  accounts  for  all  these  facts, 
although  malaria  is  much  commoner  than  syphilis  as  a  cause  of  splenic 
enlargement.  This  patient  certainly  had  no  acute  or  present  malarial 
affections  and,  in  view  of  his  residence,  there  is  no  probability  of  any 
chronic  malaria  or  any  tropical  disease  such  as  might  cause  enlarge- 
ment of  the  spleen. 

Lymphoblastoma  (Hodgkin's  disease)  produces  just  such  a  spleen 
and  such  a  simple  adenitis,  but  would  not  account  for  the  scar  on  the 
frenum  nor  for  the  changes  in  the  shin. 

Banti's  disease  and  splenic  anemia  cannot  be  excluded,  but  these 
are  diagnoses  which  should  never  be  made  unless  syphilis  can,  with 
all  reasonable  probabiHty,  be  excluded,  and  such  exclusion  is  certainly 
not  yet  possible  here. 

Against  syphilis  we  have  no  evidence  except  the  healthiness  of  the 
patient's  children.  This  cannot  be  considered  evidence  of  any  impor- 
tance. The  bunch  of  rales  and  the  changes  in  respiration  noticed  on 
September  ist  lead  us  to  speculate  as  to  whether  tuberculosis  may  not 
cause  some,  if  not  all,  of  his  symptoms.  These  pulmonary  signs, 
however,  were  not  constant  and  it  was  impossible  to  lay  much  stress 
upon  them. 

Outcome. — The  patient  did  well  under  antisyphihtic  treatment 
and  left  the  hospital  on  the  loth  of  September. 

Case  27 

A  porter  of  thirty-eight  entered  the  hospital  November  7,  19 10. 
The  patient  was  in  the  New  York  City  Hospital  two  years  ago  for 
swelHng  and  pain  in  his  ankles.     He  had  chancre  fourteen  years  ago, 


96 


DIFFERENTIAL  DIAGNOSIS 


after  which  he  doctored  for  two  or  three  months,  but  took  no  inunc- 
tions. Ten  years  ago  his  hair  gradually  fell  out.  Five  years  ago  there 
were  red  spots  on  his  hands  and  over  his  body ;  these  lesions  soon  dis- 
appeared wheii  he  took  mercury  to  the  point  of  salivation.  He  has 
been  married  two  years.  His  wife  has  had  no  children  and  no  mis- 
carriage.    He  takes  a  pint  of  whisky  a  week. 

For  about  one  year  he  has  had  frequent  headaches,  which  are 
unusual  for  him.     They  are  bilateral  or  frontal,  and  confined  mostly  to 


Fig.  42. — Lump  described  in  Case  27. 

the  afternoon  and  evening.  He  uses  his  eyes  a  good  deal  and  has  had 
no  examination  of  them.  Later,  in  September,  19 10,  for  the  first 
time  in  his  life,  he  had  a  fit  just  when  leaving  his  shop  at  the  end  of 
the  day.  He  fell  unconscious  and  remained  so  for  ten  minutes,  nearly 
or  quite  motionless.  After  resting  fifteen  minutes  he  seemed  to  be 
as  well  as  usual,  but  since  then  has  had  four  similar  attacks,  the  last 
one  today  at  noon.  Though  he  is  always  conscious  of  the  immediate 
approach  of  the  seizure,  he  has  never  been  quick  enough  to  lie  down 
before  he  fell,  and  has  bruised  himself  several  times.  He  has  never 
bitten  his  tongue  or  passed  urine  during  an  attack. 


ABDOMINAL  AND   OTHER  TUMORS  97 

Three  weeks  ago  he  first  noticed  a  lump  on  his  breast  bone.  It 
has  rapidly  increased  in  size  since  then  and  has  become  tender.  His 
appetite,  digestion,  and  sleep  are  good  and  he  feels  well  in  most 
respects. 

Physical  examination  shows  good  nutrition.  The  right  pupil  is 
greater  than  the  left,  irregular  in  shape,  and  does  not  react  either 
to  Ught  or  distance.  The  left  pupil  reacts  slightly  to  distance,  not 
at  all  to  light.  The  lymph-glands  are  enlarged  in  the  neck  and  groins. 
Knee-jerks  and  plantars  are  normal.  The  heart  and  lungs  negative, 
likewise  the  abdomen.  There  is  a  large  scar  on  the  frenum  with  a 
considerable  area  of  erosion.  The  skull  is  smooth.  The  right  shin 
shows  thickening  and  elevation  in  the  lower  third.  In  the  region  shown 
in  Fig.  42  is  a  rounded  eminence,  i|  cm.  in  height,  slightly  painful  on 
palpation,  showing  no  thrill  or  pulsation.  Percussion  over  it  is 
resonant. 

On  the  night  of  entrance  he  had  a  convulsion  lasting  three  min- 
utes. 

Discussion. — Such  a  lump  upon  the  sternum  might  be  due  to  tuber- 
culosis, to  a  neoplasm,  to  aneurysm  or  gumma,  but  the  rest  of  the 
patient's  history  should  incline  our  judgment  strongly  in  favor  of  one 
of  these  alternatives  and  against  the  rest.  The  condition  of  the 
pupils,  of  the  glands,  of  the  shin-bone,  when  taken  in  connection  with 
the  sudden  onset  of  headaches  and  fits  and  with  the  syphilitic  history, 
makes  it  obHgatory  that  we  should  exclude  syphihs  by  the  therapeutic 
tests  before  seriously  considering  any  other  disease.  If  syphihs  is 
the  underlying  disease,  the  tumor  is,  in  all  probabihty,  a  gumma,  since 
there  is  no  other  evidence  of  aneurysm. 

The  headaches  and  fits  may  be  the  result  of  an  early  dementia 
paralytica  or  of  a  syphilitic  meningitis.  Between  these  two  possibiHties 
one  could  decide  only  by  a  study  of  the  patient's  mental  condition 
and  by  the  subsequent  course  of  the  case. 

Outcome. — The  next  day  6  mg.  of  "606"  was  given  intramuscularly. 
This  produced  great  pain  and  no  demonstrable  change  in  the  tumor. 
Wassermann  reaction  was  positive.  He  left  the  hospital  on  Novem- 
ber 15  th. 

Case  28 

A  man  of  thirty-two,  a  manufacturer  of  x-ray  apparatus,  entered 
the  hospital  November  16,  1910.  The  patient  came  for  treatment  for 
swelling  over  the  right  eye.  His  general  health  has  been  ordinarily 
good.    He  had  typhoid  fever  at  twelve  years  and  has  been  subject  to 

Vol.  II— 7 


98  DIFFERENTIAL  DIAGNOSIS 

nasal  catarrh  for  many  years.  He  had  all  the  evidences  of  syphilis 
fourteen  years  ago  and  was  treated  with  mercury  for  a  year  or  more. 
He  uses  whisky  occasionally  to  excess.  Early  in  September,  1910,  he 
suddenly  fell  unconscious  and  remained  so  for  an  hour.  Afterward 
he  felt  dazed  and  vomited  twice  in  the  evening,  but  walked  a  mile 
and  a  half  to  his  train  without  help.  Next  day  he  had  in  the  right  half 
of  the  forehead  a  severe  pain,  which  has  continued  ever  since,  though 
less  in  intensity.  He  got  no  relief  from  hot-water  bag  or  cracked  ice. 
His  eyesight  was  excellent.  Since  his  first  unconscious  attack  he 
has  had  several  other  attacks  at  intervals  of  several  weeks.  In  the 
latter  part  of  September  a  swelling  appeared  above  the  right  eye- 
brow. It  gradually  increased  in  size  and  became  tender.  As  the 
swelling  increased  the  headache  lessened  in  intensity,  but  for  the  past 
two  days  it  has  again  become  aggravated.  At  the  onset  of  these 
troubles  the  patient  was  working  very  hard  and  sleeping  very  little. 
His  appetite  was  also  poor  and  he  lost  about  20  pounds,  which  he  has 
since  regained.     He  now  eats  ravenously. 

On  physical  examination  the  man  did  not  look  sick  and  was  well 
nourished.  The  right  pupil  was  greater  than  the  left  and  was  irregular 
in  outline.  Both  reacted  normally.  Glands  and  reflexes  not  ab- 
normal. Aortic  second  sound  not  accentuated.  Systolic  blood-pressure, 
145  mm.  Hg.  Chest  and  abdomen  otherwise  normal.  There  was  a 
scar  on  the  frenum  and  the  right  epididymis  was  slightly  thickened 
and  nodular.  His  shins  were  smooth,  but  showed  depressed  and 
pigmented  scars.  Over  the  right  eyebrow  was  a  soft  oval  tumor, 
about  I  by  2  inches.  It  was  tender  and  fluctuant  throughout. 
The  bone  about  the  periphery  of  the  tumor  was  roughened  and 
raised. 

Discussion. — Summarizing  the  patient's  history,  we  have  here 
evidence  of  a  syphilitic  infection,  followed  fourteen  years  later  by 
headaches,  fits,  and  a  swelling  over  the  right  eye.  Physical  examina- 
tion shows  abnormal  pupils,  a  scar  on  the  frenum,  a  thickening  of  the 
epididymis,  scars  on  the  shins,  and  a  soft  tumor  on  the  frontal  bone. 
Taken  together,  all  of  this  evidence  points  very  strongly  toward  the 
diagnosis  of  syphilitic  gumma. 

The  scars  on  the  shins  are  very  possibly  due  to  trauma  or  to 
varicose  ulcers.  We  should  be  very  careful  not  to  attribute  syphilis 
to  any  patient  merely  or  largely  on  the  evidence  of  shin  scars.  I  do 
not  beheve  there  are  any  characteristic  peculiarities  by  which  we  can 
distinguish  shin  scars  of  syphihs  from  those  produced  by  the  other 
causes   just  named. 


ABDOMINAL  AND    OTHER   TUMORS  99 

Outcome. — He  was  given  "606"  November  i6th,  and  within  six- 
teen hours  the  tumor  had  decreased  two-thirds  in  size  and  lost  its 
tenderness.  On  the  21st  about  i  ounce  of  pus  was  discharged  from 
one  nostril.  It  contained,  apparently,  no  spirochetes.  On  this  date 
the  frontal  tumor  was  apparently  gone.  The  patient  gained  4  pounds, 
and  was  discharged  on  the  23d. 

Case  29 

An  Italian  housewife  of  forty- two  entered  the  hospital  March  31, 
191 1.  The  patient's  father  died  at  fifty-seven  of  "abscess  near  the 
heart."  One  brother  died  of  cancer  of  the  intestines.  One  sister 
died  of  shock.  Three  brothers  and  one  sister  are  living  and  well. 
No  other  cancer  in  the  family  except  that  noted.  The  patient  has 
been  married  eight  years,  has  two  living  children,  and  has  had  two 
miscarriages. 

The  patient's  general  health  has  never  been  very  good.  At  nine 
she  had  ulcerations  of  the  cornea,  which  healed  at  fifteen,  and  she 
has  been  troubled  with  her  eyesight  at  intervals  ever  since.  At  twenty- 
three  she  had  another  illness  characterized  by  vomiting,  diarrhea,  and 
fainting  spells.  She  has  had  loose  movements  of  the  bowels  at  times 
ever  since.  She  has  had  frequent  attacks  of  tonsillitis.  Her  tonsils 
were  removed  two  years  ago,  the  operation  being  followed  by  a  severe 
attack  of  bronchitis. 

For  twelve  years  she  has  been  troubled  with  eructations  of  gas 
and  sharp  epigastric  pain  occurring  about  an  hour  after  meals,  some- 
times associated  with  vomiting.  She  has  never  vomited  blood. 
This  trouble  is  benefited  by  liquid  and  other  soft  diet.  There  is  no 
relief  from  soda.  Since  Christmas  she  has  had  severe  intermittent 
headache,  especially  when  tired,  not  associated  with  vomiting.  This 
headache  has  been  better  for  the  past  month  since  she  has  been  diet- 
ing and  resting.  Her  appetite  is  good,  her  bowels  move  daily.  She 
has  done  her  usual  housework  until  two  weeks  ago.  Up  to  seven 
years  ago  she  worked  as  a  seamstress. 

Five  years  ago  she  first  noticed  a  mass  in  the  epigastrium,  and 
since  then  she  has  observed  a  slow  increase  in  its  size.  There  is  no 
pain  associated  with  it  except  when  she  is  indiscreet  in  her  diet,  but 
she  says  that  all  her  life  she  has  been  bothered  by  pain  in  the  left 
ovary.  She  thinks  in  the  course  of  the  last  two  years  she  has  lost  10 
or  12  pounds  in  weight. 

Physical  examination  shows  good  nutrition,  a  garrulous,  ner\^ous 
patient.     Pupils,  glands,  and  reflexes  normal.     Chest  negative  except 


lOO 


DIFFERENTIAL  DIAGNOSIS 


for  a  soft,  blowing,  systolic  murmur  over  the  whole  precordia,  best 
heard  at  the  apex.  The  right  kidney  is  felt  with  ease.  Reaching 
across  the  epigastrium  in  the  region  shown  in  Fig.  43  is  a  hard,  irreg- 
ular, very  movable  tumor,  free  from  tenderness,  about  5  cm.  above 
the  navel.  There  is  also  tenderness  in  the  left  ovarian  region.  Blood- 
pressure,  115  mm.  Hg.  Weight,  without  clothes,  121  pounds  at 
entrance;  i2  2§  pounds  two  weeks  later.  Blood  and  urine  negative. 
Fundus  oculi  negative.  Two  examinations  of  the  stools  were  made, 
one  showing  a  negative  guaiac  reaction,  the  other  a  positive  reaction. 


Fig.  43. — Mass  felt  in  Case  29. 

The  gastric  secretions  are  normal.  The  stomach  was  inflated  and 
found  to  be  in  normal  position  and  apparently  above  the  tumor, 
which  seems  to  be  attached  to  the  greater  curvature.  The  colon 
seems  to  have  no  connection  with  the  tumor. 

Discussion. — What  were  the  nature  of  the  illnesses  which  this 
patient  had  at  fifteen  and  at  twenty- three?  I  can  form  no  reason- 
able conjecture.  We  learn  only  that  she  has  had  a  tendency  to  bowel 
trouble,  and  that  for  the  past  twelve  years  she  has  been  having  a 
dyspepsia  which  does  not  correspond  symptomatically  to  any  single. 


ABDOMINAL  AND   OTHER   TUMORS  lOI 

well-marked  clinical  type.  That  is,  it  is  not  strikingly  characteristic 
of  gastric  cancer,  gastric  ulcer,  or  any  other  clinical  entity.  The  most 
notable  fact  in  the  case  is  the  presence  of  the  epigastric  mass  which 
the  patient  has  noticed  for  five  years.  Such  a  combination  of  facts 
is  very  unusual.  A  mass  noticed  in  this  situation  for  a  few  months  or 
even  for  a  year  is  common  enough,  but  slow-growing  tumors  are  very 
rarely  found  in  the  epigastrium.  Those  connected  with  the  pancreas 
and  with  the  abdominal  wall  are  almost  the  only  exceptions  to  this 
statement.  We  have  no  right  to  say  that  cancer  of  the  stomach  can- 
not exist  for  five  years  and  produce  such  a  tumor  as  is  here  described, 
but  certainly  such  a  history  is  very  rare,  especially  as  the  patient  has 
lost  only  lo  or  12  pounds,  and  those  in  the  last  two  years. 

It  is  quite  possible,  however,  that  the  tumor  which  she  has  felt 
(assuming  that  her  statement  is  correct)  was  originally  a  perigastric 
exudate,  originating  in  a  peptic  ulcer  which  later  became  cancerous. 
Pathologists  are  sharply  divided  on  the  question  whether  or  not 
peptic  ulcer  often  becomes  cancerous,  and  no  authoritative  solution 
of  the  question  can  be  given  at  the  present  time. 

Lesions  originating  in  the  pancreas  or  in  the  abdominal  wall 
can  be  ruled  out  in  this  case:  the  first,  because  the  tumor  is  very- 
movable;  the  second,  because  it  was  demonstrably  unconnected  with 
the  abdominal  wall.  Under  these  conditions  gastric  cancer  seems 
the  most  probable  diagnosis,  despite  the  prolonged  history,  despite 
the  absence  of  emaciation,  and  the  negative  results  of  gastric  ex- 
amination. I  regret  that  no  bismuth  x-ray  test  was  made  in  this 
case. 

Outcome. — April  15th  the  abdomen  was  opened,  and  immediately 
below  the  epigastric  incision,  which  was  in  the  median  line,  there 
presented  an  elongated  mass  of  hard,  fused  glands  which  were  situated 
in  the  omentum,  along  the  greater  curvature  of  the  stomach,  which 
region  was  also  itself  infiltrated  with  neoplastic  tissue.  Large  hard 
glands  were  also  felt  around  the  pylorus.  The  pylorus  was  free  and 
there  was  no  infiltration  for  a  distance  of  2  inches  above  it.  The  flanks 
and  pelvis  were  normal.  No  operation  was  done.  The  patient 
promptly  recovered  and  left  the  hospital  on  the  23d. 

She  lived  until  March  9,  191 2,  dying  gradually  from  exhaustion. 

Case  30 

A  farmer  of  forty,  an  Italian,  entered  the  hospital  April  14,  191 1. 
The  patient's  family  and  past  history  show  nothing  of  interest.  He 
had  felt  perfectly  well  until  January,  191 1,  when  he  began  to  have 


I02 


DIFFERENTLA.L   DIAGNOSIS 


epigastric  pain  which  has  persisted  since  and  is  increased  by  food. 
Six  weeks  ago  he  noticed  a  lump  and  pain  above  his  left  clavicle. 
For  several  weeks  he  has  taken  only  liquids.  He  never  vomits. 
His  weight  in  November  was  145  pounds,  with  clothes;  now,  104^ 
pounds,  without  clothes. 

Physical  examination  shows  obvious  loss  of  weight,  though  the 
patient  cannot  be  said  to  be  emaciated.  The  pupils  react  slug- 
gishly to  light,  normally  to  distance.  Over  the  left  clavicle  is  a  mass 
the  size  of  a  chestnut,  hard,  freely  movable,  not  tender.     No  other 


Fig.  44. — Mass  felt  in  Case  30. 


evidence  of  glandular  enlargement.  The  chest  is  negative,  save  for  a 
few  groaning  rales  at  the  right  apex.  Abdomen  shows  a  hard,  nod- 
ular mass  in  the  epigastrium  (Fig.  44).  This  mass  moves  freely 
with  respiration  and  fades  out  into  an  indefinite  resistance  which 
disappears  below  the  costal  margin.  Only  its  lower  edge  is  distinctly 
felt.  The  knee-jerks  and  Achilles'  jerks  are  not  obtained,  even  on 
reinforcement.  There  is  sHght  edema  along  the  shins.  Blood  and 
urine  negative. 

The  patient's  temperature  during  the  first  week  in  the  hospital 


ABDOMINAL  AND    OTHER   TUMORS  103 

rose  to  99.5°  F.  every  evening  except  two,  when  it  went  to  ioo°  and 
to  100.5'^  F.  During  the  second  week  of  his  stay  the  temperature 
was  normal.  Blood-pressure,  105  mm.  Hg.  at  entrance;  130  mm.  Hg. 
ten  days  later.  The  stomach-tube  showed  no  food  in  the  fasting 
stomach,  and  after  a  test-meal  the  stomach  contained  no  hydrochloric 
acid  and  the  wash- water  was  positive  to  guaiac.     There  were  no 

sarcinae.  -^  .^^^  U.JlA^/^  ^ 

Discussion. — The  essential  points  in  this  ca^e^ate:  '     '      '^ 

First,  A  history  of  three  months'  dyspnea  with  loss  of  weight  and 
with  masses  in  the  epigastrium. 

Second,  A  painful  lump  noticed  for  six  weeks  over  his  left  collar- 
bone. 

Third,  An  Argyll-Robertson  pupil  and  an  absence  of  knee-jerks. 

Fourth,  A  slight  fever. 

Tabes  should  be  our  first  thought  when  a  patient  with  such  pupils 
and  reflexes  as  this  patient  presents  complains  of  any  sort  of  abdominal 
discomfort.  The  mass  over  the  clavicle  might  quite  conceivably 
represent  a  syphilitic  adenitis,  and  the  mass  in  the  epigastrium  the 
edge  of  a  syphilitic  liver.  This  diagnosis  is  all  the  more  probable  be- 
cause of  a  slight  fever.  It  is  to  be  regretted  that  no  Wassermann 
test  was  done  in  this  case.  Certainly  syphilis  cannot  be  excluded 
without  such  a  test  and  without  trying  the  effects  of  antisyphilitic 
treatment. 

Gastric  cancer  might  well  account  for  the  mass  in  the  epigastrium 
and,  by  metastasis,  for  the  lump  above  the  clavicle.  The  stomach 
symptoms  arising  suddenly  in  a  patient  who  has  never  had  stomach 
trouble  before  and  who  is  now  forty  years  old,  certainly  suggest 
cancer,  but  cancer  will  not  account  for  the  condition  of  the  pupils 
and  reflexes,  and  if  we  decide  to  call  the  case  one  of  cancer  we  must 
also  make  a  diagnosis  of  early  tabes  dorsalis  as  a  separate  malady. 

Tuberculous  peritonitis  is  suggested  by  the  presence  of  fever  and 
by  the  patient's  race,  since  this  disease  is  especially  common  among  the 
Italians  in  Boston  and  its  vicinity.  The  mass  in  the  epigastrium 
might  represent  the  rolled-up  omentum,  which  is  not  uncommon  in 
tuberculous  peritonitis.  It  is  unusual,  however,  to  see  the  disease  in  a 
patient  of  this  age.  Most  of  the  cases  of  tuberculous  peritonitis  in 
Italians  appear  in  children  or,  at  any  rate,  before  the  thirtieth  year. 

Cirrhosis  of  the  liver  would  produce  just  such  a  mass  and  would 
account  for  the  patient's  stomach  symptoms.  It  is  not  common  in 
the  Italian  immigrants,  as  one  sees  them  in  New  England,  but  this  is 
not  nearly  sufficient  to  exclude  the  disease.     The  lack  of  any  enlarge- 


I04  DIFFERENTIAL  DIAGNOSIS 

ment  of  the  spleen  is  the  most  important  consideration  against  cir- 
rhosis. 

The  four  possibiUties  just  mentioned  seem  to  me  all  that  need  to 
be  seriously  considered.  Were  the  urine  not  normal,  one  might  need 
to  consider  a  uremic  tjnpe  of  stomach  trouble,  such  as  often  appears 
in  the  arteriosclerotic  variety  of  chronic  nephritis  and  less  often  in  the 
chronic  glomerular  forms. 

All  things  considered,  gastric  cancer  with  tabes  seemed,  to 
those  who  saw  this  patient  in  the  hospital,  the  most  probable 
diagnosis. 

Outcome. — Under  cocain  the  supraclavicular  gland  was  removed. 
Examination  by  Dr.  J.  H.  Wright  showed  metastatic  adenocarcinoma. 
The  patient's  epigastric  pain  was  so  great  that  he  needed  morphin 
from  time  to  time  and  his  bowels  could  only  be  moved  by  strong 
cathartics.  He  left  the  hospital  on  the  29th,  having  lost  2  pounds 
during  his  stay. 

Case  31 

An  engraver  of  fifty-seven,  born  in  Turkey,  entered  the  hospital 
May  23,  191 1.  He  complained  of  lumps  upon  his  skull  and  in  his 
abdomen.  He  says  his  father  died  because  he  was  not  fed  enough  by 
his  wife,  who  was  too  stingy.  The  lady  in  question  is  living  and  well, 
as  are  two  brothers.  The  patient  has  four  healthy  children  and  his 
wife  has  had  no  miscarriages.  He  has  never  been  sick  before,  has  ex- 
cellent habits,  and  denies  venereal  disease.  The  patient  says  he  is  in 
perfect  health,  and  only  on  this  understanding  furnishes  us  the  follow- 
ing facts:  He  has  always  been  much  interested  in  astronomy  and  has 
ideas  about  the  creation  of  the  universe.  These  he  regards  as  of  high- 
est importance,  and  the  responsibility  of  these  ideas,  combined  with 
his  exhausting  occupation  as  an  engraver,  has  much  to  do,  he  thinks, 
with  his  present  condition.  Two  years  ago,  while  working  night  and 
day  (as  he  had  to  engrave  both  for  the  day  and  the  night  editions  of 
his  paper),  he  noticed  some  lumps  upon  his  head,  and  at  his  doctor's 
advice  took  a  trip  to  Turkey.  This  was  in  the  fall  of  1909,  and  after 
it  all  the  lumps  disappeared  and  he  busied  himself  in  explaining  to  his 
bewildered  countrymen  that  Halley's  comet  would  miss  the  earth  by 
some  80,000,000  miles.  When  the  comet  verified  this  prediction, 
he  returned  to  this  country  and  took  up  his  work  in  the  fall  of  1910. 
At  this  time  another  group  of  lumps  appeared.  They  have  grown  but 
little  since  their  appearance,  and,  except  for  one  behind  the  left  ear, 
are  not  tender.     He  has  no  actual  pain,  though  the  discomfort  asso- 


ABDOMINAL  AND    OTHER   TUMORS  I05 

dated  with  the  lumps  is  worse  if  he  gets  hungry.  His  appetite,  he 
says,  requires  attention,  but,  if  properly  cared  for,  is  excellent.  Tender 
steak  and  rice  pudding  are  his  mainstays.  More  vulgar  foods  are 
promptly  and  painlessly  ejected,  especially  if  he  sings  too  soon  after 
eating.  He  has  lost  no  weight.  He  usually  weighs  155  pounds. 
His  bowels  are  regular.  He  sleeps  well  and  declares  emphatically 
that  he  is  well. 

Physical  examination  shows  good  nutrition  and  excellent  facial 
color.  Scattered  over  the  scalp  are  many  low,  firm,  painless,  rounded 
elevations,  about  4  cm.  in  diameter,  not  sharply  circumscribed,  not 
attached  to  the  skin,  but  firmly  adherent  to  the  parts  beneath  them. 
There  is  slight  tenderness  over  the  left  mastoid.  Pupils,  lymph- 
nodes,  and  reflexes  negative.  Chest  negative  save  for  a  late,  blow- 
ing systolic  murmur,  best  heard  at  the  apex.  The  abdomen  shows 
shifting  dulness  in  the  flanks.  The  Hver  dulness  extends  from  the 
fifth  rib,  nipple  Hne,  to  a  point  7  cm.  below  the  ribs,  where  a  smooth, 
rounded,  insensitive  edge  is  felt.  The  spleen  is  considerably  en- 
larged by  percussion  and  its  smooth  edge  is  felt  12  cm.  below  the  ribs. 
The  shaft  of  the  right  humerus,  near  its  lower  end,  of  each  ulna  near 
its  lower  end,  and  of  the  femur  near  its  upper  end,  show  some  enlarge- 
ment. The  x-ray  shows  marked  increase  in  the  density  of  the  skull 
and  of  the  affected  long  bones,  with  much  roughening  of  the  perios- 
teum, but  no  rarefaction.  Wassermann  reaction  was  strongly  posi- 
tive. Blood  and  urine  negative.  Systolic  blood-pressure  150  mm. 
Hg.     No  fever  in  three  days'  observation.     Weight,  135  pounds. 

Two  members  of  the  staff  considered  the  disease  osteitis  de- 
formans. Dr.  J.  H.  Wright  considered  all  the  lesions,  both  in  the 
spleen,  liver,  and  bones,  due  to  syphiUs.  The  late  Dr.  R.  H.  Fitz 
thought  h3^ertrophy  of  the  liver  and  spleen  quite  independent. 
The  latter  represented  to  him  the  chronic  splenic  tumor  of  the  Levan- 
tine races.  He  expressed  no  opinion  as  between  osteitis  deformans 
and  syphihs.  The  patient  would  stay  in  the  hospital  but  a  short  time, 
as  he  felt  so  well.  He  was  given  iodid  of  potash,  15  gr.  three  times  a 
day,  and  allowed  to  leave  on  the  19th, 

Discussion. — The  positive  findings  in  this  case  are  an  ascites,  with 
enlargement  of  liver  and  spleen,  lesions  involving  several  bones  and  a 
number  of  subcutaneous  areas,  and  a  positive  Wassermann  reaction. 
Enlargement  of  the  spleen  is  very  common  in  Turks,  Syrians,  and 
Levantines  generally,  but  enlargement  of  the  liver  does  not  usuaUy 
go  with  it  and  requires  some  other  explanation. 

Syphilis  is  the  only  diagnosis  which  can  explain  all  the  facts. 


Io6  DIFFERENTIAL  DIAGNOSIS 

The  patient  would  not  consent  to  the  excision  of  a  subcutaneous  nodule. 
Without  this,  no  further  certainty  could  be  arrived  at. 

As  regards  the  mental  symptoms,  one  should  be  careful  and  hesi- 
tate seriously  before  attributing  such  unusual  ideas  as  this  patient 
exhibits  to  mental  disease.  In  the  average  American,  such  ideas  would 
probably  be  abnormal,  but  we  should  be  slow  to  put  our  local  stamp 
upon  all  other  nations  or  to  interpret  their  imaginative  flights  in  terms 
of  our  own  literal-minded  habits. 

SyphiHs,  then,  is  the  most  reasonable  hypothesis  on  which  to  base 
treatment.  It  should  be  observed  that  this  patient  did  not  receive 
antis}^hilitic  treatment  while  in  the  hospital. 

Outcome. — The  patient  returned  to  Turkey  June,  191 1,  and  died 
there  in  October  of  the  same  year.  Headache  was  his  chief  com- 
plaint. The  bones  of  his  forehead  and  wrists  are  stated  to  have  been 
swollen,  but  caused  no  suffering.     He  died  quietly,  without  pain. 

Case  32 

A  housewife  of  thirty-eight  entered  the  hospital  July  2,  19 10. 
The  patient's  mother  died  of  Bright's  disease  and  one  sister  of 
tuberculosis  of  the  bowels.  Otherwise  the  family  history  is  good. 
The  patient  herself  was  always  well  until  her  marriage.  Her  first 
pregnancy  ended  in  a  miscarriage  at  seven  months.  Eight  years  ago 
she  had  times  of  being  very  weak  and  pale.  Five  years  ago  she  did 
not  menstruate  for  eleven  months.  Three  years  ago  she  had  some  hard 
bunches,  the  size  of  half  a  hen's  egg,  tender  and  painful,  upon  her 
arms  and  legs  and  on  her  head.  These  grew  slowly  and  disappeared 
slowly.  While  they  were  enlarging  they  were  exceedingly  painful. 
Several  times  before  and  since  this  they  have  come  and  gone,  but 
have  never  been  as  severe  as  they  were  three  years  ago.  They  were 
never  red  or  discolored.  The  positions  of  the  lesions,  as  described, 
are  shown  in  Figs.  45,  46. 

Through  the  spring  of  this  year  she  has  been  troubled  by  general 
weakness  and  tiredness  and  sometimes  has  felt  too  weak  to  walk. 
From  time  to  time  she  has  had  sudden  attacks  of  sharp  pain  in  the 
right  side  of  the  abdomen,  radiating  to  the  groin,  and  followed  by 
soreness  between  the  attacks.  She  never  has  them  when  she  stays  in 
bed.  She  has  never  had  jaundice,  vomiting,  or  urinary  symptoms 
in  cormection  with  these  attacks,  and  has  done  her  housework  for  five 
people  until  recently.  She  used  to  weigh  114  pounds,  with  her 
clothes;  now  81  pounds,  without  clothes. 

Physical  examination  showed  poor  nutrition,  a  waxen  skin,  pale 


ABDOMINAL   AND    OTHER   TUMORS 


107 


lips.  Pupils  and  reflexes  normal.  There  were  a  few  small  glands 
in  the  neck,  many  in  the  axillae  and  groins,  of  the  size  of  peas.  Chest 
negative  save  for  a  few  fine  crackles  at  the  left  base.  The  arterial 
walls  were  apparently  thickened.  The  abdomen  was  negative. 
The    tip    of    each    kidney   was    palpable.     Wassermann    reaction 


Barrel ,  ver 

No  6\s,co\ 
"Like  bon 


Oimi  lav"  TO  rKat 
on  -j-oire  hea6 . 


T"ig.  45. — Diagram  of  described  lesiong  existing  over  a  period  of  a  year  or  more,  three 

years  ago. 

negative.  Urine  averaged  60  ounces  in  twenty-four  hours,  with  a 
specific  gravity  of  loio  to  1014,  no  albumin,  no  sugar.  No  fever  in  a 
month's  observation.  Blood-pressure,  120  mm.  Hg.,  systoHc.  Red 
cells  on  three  examinations  ranged  in  the  vicinity  of  3,800,000;  hemo- 
globin, 65  per  cent.;  leukocytes,  5000  to  7000.     Differential  count, 


io8 


DIFFERENTLA.L  DIAGNOSIS 


normal.  Slight  achromia  and  deformities  of  the  reds.  Of  ten  ex- 
aminations of  the  feces,  two  showed  a  slight  reaction  to  guaiac.  The 
cause  of  her  anemia  and  other  symptoms  remained  obscure.  Skin 
tuberculin  test  was  positive;  jc-ray  showed  sHght  thickening  of  the 
cortical  bone  on  the  anterior  surface  of  the  right  tibia. 


KaY\y  sV>ia.ll  IfVYipj 
size  o-{  walnut  . 
5aYYie  charactcr- 
very    pamful. 


Fig.  46. — Diagram  of  described  lesions  existing  over  a  period  of  a  year  or  more,  three 

years  ago. 

Discussion. — This  patient,  suffering  from  anemia,  emaciation,  an 
abdominal  pain  of  the  type  often  associated  with  renal  colic,  gives 
a  history  of  small,  tender  bunches,  which  have  appeared  and  disap- 
peared in  various  parts  of  her  body.  Examination  of  the  abdomen  is 
negative  and  there  is  no  Wassermann  reaction.     The  latter  test  threw 


ABDOMINAL  AND   OTHER  TUMORS 


109 


US  disastrously  off  the  track  at  the  time  of  this  patient's  first  entrance 
to  the  hospital.  Such  symptoms  as  she  had  had,  when  associated 
with  the  x-ray  findings  in  the  right  tibia,  should  have  led  us  to  push 
antisyphilitic  treatment,  whatever  the  blood  showed.  I  am  sure  that 
we  are  often  lead  astray  in  this  way  by  negative  Wassermann  reac- 
tions, which  are,  of  course,  nothing  like  so  significant  and  so  import- 
ant, as  guides  to  action,  as  positive  reactions. 

'  The  positive  tuberculin  reaction,  in  the  absence  of  fever  and  in  a 
woman  of  her  age,  was,  of  course,  a  matter  of  no  importance. 

At  the  time  of  her  second  entry  the  Wassermann  reaction  had 
become  strongly  positive,  and  the  mental  symptoms,  presumably  of 
syphilitic  meningitis,  made  the  diagnosis  unusually  clear.  The 
promptness  and  thoroughness 
of  her  recovery  under  anti- 
syphilitic  treatment  is  only 
what  we  have  a  right  to  ex- 
pect in  cases  of  this  type. 

Outcome. — The  patient  had 
an  operation  done  for  double 
femoral  hernia,  after  which  she 
left  the  hospital,  August  loth. 
She  returned  June  3,1911,  hav- 
ing taken  up  her  housework 
immediately  on  her  discharge 
and  continued  it  as  best  she 
could  ever  since,  though  with 
^reat  exhaustion.  For  the 
past  month  she  has  had  to  lie 
down  part  of  each  day.  Never- 
theless, in  October,  1910,  her 
weight  reached  128  pounds. 
Since  then  it  has  markedly  failed.  All  winter  she  has  had  hard, 
tender  lumps  upon  her  head  which  have  changed  lately  in  size.  She 
has  slept  very  poorly  for  some  weeks. 

Physical  examination  shows  a  thin,  exhausted  woman,  with  loose, 
dry  skin,  and  marked  pallor.  Over  the  left  eye  are  two  elevated, 
rounded  areas,  about  4  cm.  in  diameter,  covered  by  very  tense  skin, 
tender,  hard,  not  fluctuant.  Near  the  right  ear  are  two  more,  about 
the  same  size.  The  pupils  are  not  circular,  but  react  normally. 
There  seems  to  be  a  general  thickening  of  the  left  humerus.  Chest 
and  abdomen  negative.     No  edema.     Red  cells,  4,000,000;  hemo- 


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Fig.  47. — Chart  of  Case  32. 


no  DIFFERENTIAL   DIAGNOSIS 

globin,  85  per  cerrt.  The  course  of  the  temperature  is  shown  in  Fig.  47. 
Wassermann  reaction  now  strongly  positive.  Urine  negative.  Her 
husband  states  that  she  has  been  very  irrational  and  restless  at  night 
for  some  days  before  entrance,  and  this  state  continued  and  was 
aggravated,  so  that  by  the  loth  of  June  she  was  delirious  most  of  the 
time,  carrying  on  conversations  with  imaginary  persons  and  con- 
stantly trying  to  get  out  of  bed;  x-ray  showed  typical  syphiUtic 
changes  in  the  skull  and  other  bones.  On  the  20th  she  had  become 
rational  again,  but  could  not  remember  being  brought  to  the  hospital 
or  anything  during  the  first  week  of  her  stay  there.  The  patient  is 
a  nurse,  and  there  is  reason  to  believe  the  infection  was  acquired  in 
the  performance  of  her  professional  duties.  The  amount  of  iodid  of 
potash  administered  is  indicated  upon  the  chart.  By  the  24th  of  June 
she  seemed  to  be  in  very  good  condition  and  was  discharged. 

The  patient  was  seen  in  January,  19 13,  and  reported  that  she 
had  had  various  ups  and  downs  since  leaving  the  hospital  eighteen 
months  previously.  The  periostitis  upon  the  forehead  had  bothered 
her  off  and  on,  especially  at  the  time  of  the  menstrual  period,  and 
there  had  been  swellings  upon  the  arms  and  legs.  Her  general  health 
had  been  fair.     She  had  had  no  salvarsan. 

Case  33 

A  Swedish  housewife  of  thirty-four  entered  the  hospital  April  27,. 
191 1.  One  of  the  patient's  sisters  ''died  at  thirty-four  of  an  enlarged 
spleen."  This  is  now  precisely  the  patient's  age.  There  are  no 
other  known  cases  of  enlarged  spleen  in  the  family  and  no  other 
points  of  interest  in  the  family  history.  When  seventeen  the  patient 
had  a  severe  attack  of  pain  in  the  region  of  the  gall-bladder  and  was 
jaundiced  at  that  time;  she  thinks  she  has  been  yellow  at  varying 
intervals  since.  The  patient  has  had  no  menstruation  for  the  past 
four  months.  She  suspects  pregnancy.  She  has  known  that  she  had 
a  large  spleen  since  she  was  twelve  years  old.  The  lump  gradually 
grew  until  the  patient  was  nineteen,  but  not  since  that  time.  She 
has  never  had  any  pain  or  any  other  symptoms  with  it.  At  the 
present  time  her  only  symptoms  are  weakness  and  loss  of  weight. 
She  has  an  excellent  appetite  and  worked  until  yesterday.  There 
has  been  no  morning  vomiting. 

Physical  examination  showed  a  well-nourished  patient,  very  pale, 
and  with  a  yellowish  cast.  The  sclerae  showed  jaundice.  Pupils, 
reflexes,  and  glands  normal.  No  unusual  pigmentation  of  the  breasts. 
Harsh  systolic  murmur  at  the  base  of  the  heart,  transmitted  to  the 


ABDOMINAL  AND    OTHER   TUMORS 


III 


apex  and  axilla.  Pulmonic  second  sound  slightly  accentuated.  No 
evidence  of  cardiac  enlargement.  Pulses  and  arteries  not  remark- 
able.    Lungs  negative. 

The  abdomen  was  distinctly  distended  below  the  navel,  especially 
on  the  right  side.  The  edge  of  the  spleen  extended  5  cm.  below  the 
navel  and  a  notch  was  felt  on  its  median  border.  There  was  no  tender- 
ness. On  the  right  lower  quadrant  deep  palpation  outlined  a  rounded 
resistance,  dull  on  percussion  (Fig.  48). 


outUflt 


-du\v\£S5. 


-al^ation 
'■•flank  . 


Fig.  48. — Signs  in  Case  ^s,  April  27,  191 1. 


The  uterus  appeared  to  be  symmetrically  enlarged  and  about  the 
size  of  an  orange.  Blood-pressure,  115  mm.  Hg. ;  urine  negative.  Blood 
as  described  below.  Stools  always  negative  to  guaiac.  Urine  nega- 
tive. No  bile.  Wassermann  reaction  negative.  After  purgation 
the  mass  on  the  right  side  seemed  larger,  more  movable,  and  quite 
distinct  from  the  fundus  uteri.  The  mass  felt  cystic  to  the  examining 
hand.  The  cervix  uteri  was  normal  and  there  were  no  concomitant 
evidences  of  pregnancy.  During  two  months'  observation  tempera- 
ture, pulse,  and  respiration  remained  normal.  The  patient  gained 
3  pounds.     There  was  no  change  in  the  size  of  the  uterus.     She  left 


112 


DIFFERENTIAL  DIAGNOSIS 


the  hospital  June  14th  and  returned  July  loth.  There  had  been  then 
no  considerable  change  in  her  condition  and  no  menstruation.  Fetal 
movements  could  now  be  felt  and  there  was  a  placental  souffle  in 
the  right  lower  quadrant.  The  fetal  heart  was  not  heard.  Secretion 
was  expressed  from  the  enlarged  breasts.  The  cervix  was  slightly 
elongated  and  softened. 

At  this  time  she  remembered  that  one  maternal  aunt  was  always 
very  pale,  but  not  yellow,  and  died  in  middle  age  of  heart  trouble  and 
chronic  cough.     She  stated  that  she  herself  was  very  pale  before 


Fig.  49. — Condition  of  patient  July  10,  igii. 

the  appearance  of  the  splenic  enlargement,  but  did  not  become  yellow 
until  that  time.  She  has  noticed  no  change  in  the  color  of  the  stools 
and  has  had  no  severe  attacks  of  diarrhea.  She  is  never  unduly 
somnolent,  and  has  had  no  articular  pains  and  no  very  definite  stomach 
symptoms.  She  has  had  some  indigestion  brought  on  by  strong 
emotion  or  by  worry,  and  she  thinks  that  at  such  times  her  yellowness 
becomes  more  pronounced. 

Slight  edema  of  the  legs  was  noticed  at  this  time.     The  number  of 
red  corpuscles  ranged  close  to  2,000,000,  for  the  three  weeks  of   her 


ABDOMINAL   AND    OTHER   TUMORS 


113 


stay  in  the  hospital;  hemoglobin  about  60  per  cent.,  leukocytes  6000. 
Smear  showed  slight  achromia,  many  large  well-stained  red  cells, 
sHght  variations  in  shape,  considerable  variations  in  size,  many 
stippled  and  abnormally  stained  cells.  On  the  29th  of  July  four  nor- 
moblasts and  one  megaloblast  were  seen.  The  condition  of  the 
abdomen  July  loth  is  shown  in  Fig.  49.  The  red  cells  showed 
increased  fragility,  in  that  hemolysis  began  in  the  patient's  blood 
when  a  y^  per  cent,  saline  solution  was  added.  She  left  the  hospital 
August  2d. 

This  patient's  sister  was  persuaded   to   enter   the   hospital   for 
observation.     Her  spleen  was  also  considerably  enlarged  (Fig.  50). 


Fig.  50. — Signs  in  patient's  sister. 


Red  cells,  3,300,000;  white  cells,  7000;  hemoglobin,  65  per  cent. 
Smear  practically  the  same  as  her  sister's.  The  reds  showed  increased 
fragility.  Wassermann  reaction  negative.  Urine  negative.  This 
patient  has  been  yellow  since  twenty,  but  has  always  been  up  to  her 
work.  Her  present  age  is  thirty-six  and  she  complains  of  nothing. 
The  spleen  extended  from  the  eighth  rib,  midaxillary  line,  to  a  point 
4  cm.  below  the  ribs. 

Discussion. — Clearly,  the  abdominal  tumor  present  in  this  case 

Vol.  II— 8 


114  DIFFERENTLA.L  DIAGNOSIS 

represents  an  enlarged  spleen  associated  with  that  ill-defined  but 
most  interesting  disease  variously  known  as  family  jaundice,  con- 
genital jaundice,  acholuric  jaundice,  hemolytic  jaundice,  etc.  Doubt- 
less some  cases  of  this  type  merge  into  those  called  by  that  equally 
vague  term,  Banti's  disease  (splenic  anemia),  or  into  the  Hanot 
type  of  cirrhosis.  There  is  nothing,  however,  in  this  case  to  suggest 
any  involvement  of  the  liver,  and  without  that  none  of  the  diagnoses 
just  mentioned  could  be  justified. 

The  chief  interest  in  cases  of  this  type  is  the  very  notable  degree 
of  success  which  has  followed  splenectomy  in  this  and  in  all  other 
types  of  anemia  demonstrably  associated  with  pathologic  hemolysis 
and  an  enlarged  spleen.  While  this  operation,  splenectomy,  has 
within  the  past  year  been  used  quite  unjustifiably  in  other  dis- 
eases associated  with  anemia  and  with  enlarged  spleen,  and  while 
there  is  no  justification  for  attempting  it  in  pernicious  anemia,  in 
leukemia,  or  in  any  case  of  well-developed  liver  cirrhosis,  it  certainly 
is  of  great  value  in  typical  cases  of  splenic  anemia  and  in  some  phases 
of  the  disease  represented  in  the  case  just  discussed. 

I  append  here  some  details  descriptive  of  the  stained  smears  of  the 
patient's  blood  at  different  stages  of  her  disease: 

April  27th.  Smear  shows  considerable  variation  in  size,  but  only 
slight  variation  in  shape  of  red  blood-corpuscles.  No  achromia,  six 
normoblasts,  no  megaloblasts  seen.     No  stippling. 

May  2d.  Variation  in  size  very  marked,  variation  in  shape  slight; 
marked  polychromatophilia,  with  many  coarse  and  fine  stippled  cells. 

May  8th.     Same.     Blasts  fewer. 

May  nth.  Still  considerable  variation  in  size.  Variation  in 
shape  not  marked,  but  greater  than  before.  Stippling  rare.  Eleven 
normoblasts  and  one  megaloblast  in  count  of  100  cells. 

May  20th.     No  notable  change  except  disappearance  of  blasts. 

June  6th.  Still  great  variation  in  size,  very  little  variation  in 
shape,  four  normoblasts. 

Outcome. — The  patient  was  seen  in  February,  19 13,  eighteen 
months  after  she  had  left  the  hospital,  and  seemed  to  have  improved 
very  notably.  Her  weakness  and  anemia  began  to  leave  her  about 
four  months  after  her  hospital  experience,  and  from  that  time  on  she 
has  felt  pretty  well  and  has  done  all  the  housework  for  a  family  of  two. 
Her  menstruation  has  been  absent  for  the  past  three  months.  She 
has  no  pain,  no  cough,  and  an  excellent  appetite. 


ABDOMINAL   AND    OTHER   TUMORS 


115 


Case  34 

A  motorman  of  thirty-eight  entered  the  hospital  July  25,  191 1. 
The  patient's  family  history  and  past  history  show  nothing  of  inter- 
est, though  he  has  had  constipation  and  indigestion  for  years.  When 
constipated  he  has  gas  and  epigastric  heaviness  after  meals,  his  tongue 
is  coated,  and  he  feels  tired  and  sleepy.  When  the  bowels  move,  these 
symptoms  disappear  entirely. 

For  ten  months  he  has  noticed  constant  soreness  and  a  tender 
lump  in  the  right  lower  quadrant.     The  lump  was  at  first  soft,  but 


Fig.  51. — Lump  felt  in  Case  34. 


has  grown  harder  and  more  easily  palpable.  It  troubles  him  more 
when  he  is  constipated  and  when  he  walks  much,  but  he  never  has 
what  he  calls  "real  pain"  there.  Six  months  ago  this  symptom  pre- 
vented his  working  for  two  weeks,  and  three  weeks  ago  he  was  dis- 
abled during  a  period  of  hot  weather.  Over  the  whole  abdomen  he  had 
severe  cramp-like  pains  which  followed  the  drinking  of  a  large  amount 
of  ice-water.  He  thinks  that  the  size  of  the  lump  has  not  increased 
since  he  first  noticed  it.     It  has  always  been  about  as  large  as  a  hen's 


Il6  DIFFERENTIAL   DL\GN0SIS 

egg.  The  patient  eats  and  sleeps  well,  but  has  chronic  constipation 
of  moderate  severity. 

Physical  examination  shows  a  patient  who  is  the  picture  of  health 
and  is  altogether  negative  except  as  concerns  the  abdomen  (Fig.  51), 
where  there  is  a  mass  the  size  of  a  hen's  egg,  somewhat  tender,  not 
moving  with  respiration,  slightly  dull  on  percussion.  Otherwise  the 
abdomen  is  also  negative.  The  blood  and  urine  show  nothing  abnormal. 
The  patient  had  no  temperature  in  three  days'  observation. 

Discussion. — With  a  lump  in  the  region  of  the  cecum  one  has  al- 
ways to  consider  especially  cancer  of  the  cecum,  appendix  abscess, 
and  pericecal  tuberculosis.  The  latter  disease  does  not  often  begin 
in  a  man  of  this  age.  It  would  also  probably  be  associated  with  some 
fever  and  the  palpable  mass  would  be  less  sharply  outlined  and  cir- 
cumscribed. 

An  appendix  abscess  would  hardly  persist  so  long  unchanged. 
Ten  months  without  more  variation  in  symptoms  or  signs  is  a  very 
long  period  for  an  appendix  abscess. 

Against  cancer  of  the  bowel  we  have  nothing  except  the  fact 
that  the  patient  is  the  picture  of  health.  It  seems  extraordinary 
that  a  cancer  which  has  existed  as  long  as  we  have  reason  to  beheve 
it  has  in  this  patient  should  have  affected  the  patient's  general  condi- 
tion to  so  trifling  an  extent.  This  consideration  led  me  to  think 
that  a  pericecal  exudate,  dependent  upon  an  inflamed  appendix, 
was  the  most  probable  diagnosis. 

Outcome. — On  the  28th  of  July  the  abdomen  was  opened  and  the 
cecum  found  to  be  involved  in  a  hard  mass  of  tissue,  apparently  not 
inflammatory,  but  more  like  malignant  disease.  This  mass  extended 
up  about  I  inch  into  the  bowel,  which  was  bound  to  the  mass.  The 
base  of  the  appendix  was  apparently  normal.  Its  tip  was  lost  in  the 
mass  above  mentioned.  A  bit  of  the  tumor  was  excised,  and  when 
examined  in  frozen  section  seemed  to  be  not  inflammatory  or  tuber- 
culous, but  probably  new-growth.  There  was  no  obstruction  and 
further  operation  was  deemed  inadvisable.  No  further  examination 
of  the  tumor  is  on  record.  The  patient  had  an  uninterrupted  con- 
valescence and  left  the  hospital  on  the  14th  of  August. 

The  patient  died  at  his  own  home  January  26,  19 13.  There  was 
no  autopsy. 

Case  35 

A  housewife  of  forty-three  entered  the  hospital  July  25,  191 1. 
Her  family  history  and  past  history  are  negative.     For  the  past  four 


ABDOMINAL  AND   OTHER   TUMORS 


117 


years  she  has  noticed  an  occasional  soreness  in  the  right  hypochon- 
drium,  usually  at  night  when  changing  her  position  in  bed.  This 
motion  sometimes  is  followed  by  a  sharp,  brief  stitch. 

Two  years  ago  she  had  an  attack  of  vomiting  in  the  night,  not 
accompanied  by  pain,  and  leaving  her  as  well  as  ever  after  a  day  or 
two.  Four  weeks  ago  she  awoke  at  night  with  nausea,  but  without 
pain,  and  vomited  almost  constantly  until  morning.  This  vomiting 
recurred  the  following  night  and  was  accompanied  by  fever  and  recur- 
ring chilly  sensations.     There  has  been  no  jaundice,  but  since  the 


Fig.  52. — Mass  felt  in  Case  35. 


attack  she  has  felt  weak,  has  had  no  appetite,  has  lost  16  pounds  in 
weight,  and  has  become  conscious  of  a  lump  in  the  upper  right  corner 
of  the  abdomen  which  occasionally  is  somewhat  painful. 

Physical  examination  shows  obesity,  no  jaundice,  pupils,  glands, 
and  reflexes  normal.  The  chest  is  negative  save  for  a  soft  systolic 
murmur,  loudest  at  the  apex,  transmitted  over  the  precordia  and  to 
the  anterior  axillary  line.  Aortic  second  is  greater  than  the  pulmonic 
second.  Peripheral  arteries  not  abnormal.  SystoHc  blood-pressure, 
135  mm.  Hg.  In  the  right  upper  quadrant  is  an  irregular,  smooth, 
rounded  mass,  descending  with  inspiration,  but  very  slightly  movable 
laterally.  A  blunt  edge,  apparently  the  liver,  is  felt  in  the  flank.    There 


Il8  DIFFERENTIAL   DIAGNOSIS 

is  no  tenderness  to  speak  of.  The  mass  is  dull  on  percussion.  The 
upper  border  of  liver  dulness  is  at  the  sixth  rib  (Fig.  52).  Leukocytes, 
12,000;  hemoglobin,  85  per  cent.  Urine  negative.  Fever  during 
ten  days'  observation  usually  reaches  99.8°  F.  at  night.  The  patient 
has  lost  10  pounds  in  these  ten  days.  No  fluctuation  or  elasticity  is 
detected.  Bimanual  transmission  to  the  back  is  clear.  Such  pain  as 
she  has  is  referred  to  the  right  groin  and  the  right  iliac  region.  The 
mass  is  believed  to  be  a  dilated  gall-bladder  and  the  cause  suspected 
to  be  cancer. 

Discussion. — When  a  fat,  middle-aged  woman  complains  of  stitch- 
like pain  in  the  region  of  the  gall-bladder,  extending  over  a  period  of 
four  years,  one  necessarily  considers  gall-stones  before  studying  any 
other  possibility.  Some  affection  of  the  gall-bladder  is  made  more 
probable  by  the  presence  of  a  lump,  such  as  is  shown  in  Fig.  52. 
It  is  an  unusual  and  rather  inexplicable  feature  of  the  case  that  her 
pain  seems  to  be  associated  especially  with  change  of  position.  Un- 
usual, also,  is  the  occurrence  of  attacks  of  nocturnal  vomiting,  without 
abdominal  pain.  Moreover,  we  do  not  expect  a  distended  gall- 
bladder to  be  palpable  bimanually,  as  an  enlarged  kidney  is,  with 
one  hand  in  the  lumbar  region  below  the  last  rib. 

Despite  these  unusual  features,  it  seems  to  me  that  in  diagnosis 
we  can  certainly  go  so  far  as  to  say  that  some  trouble  in  or  about  the 
gall-bladder  is  the  most  probable  solution  of  our  problem.  It  remains 
to  inquire  whether  we  are  dealing  with  a  neoplasm,  a  distention  of  the 
gall-bladder  from  stone  in  the  cystic  duct,  or  with  an  inflammatory 
exudate  in  or  about  that  viscus.  The  absence  of  jaundice  encourages 
us  to  believe  that  there  is  no  neoplasm  present.  The  presence  of  fever 
favors  an  infection.  Beyond  this,  I  do  not  see  that  we  have  grounds 
for  further  diagnostic  speculation. 

Outcome. — Operation,  August  5th,  showed  that  the  mass  was  made 
up  largely  of  omentum  adherent  to  the  liver  above.  The  liver  edge 
extended  almost  as  low  as  the  navel.  The  adhesions  between  the 
liver  and  the  omentum  were  broken  through  and  i}  ounces  of  thick 
pus  was  evacuated  either  from  the  gall-bladder  or  from  the  region 
immediately  about  it.  Several  stones,  the  size  of  filberts,  were  found 
in  the  gall-bladder  and  in  two  crypts  in  the  gall-bladder  walls,  as 
though  ulceration  had  taken  place.  One  pocket  which  extended  up- 
ward from  the  junction  of  the  gall-bladder  with  the  cystic  duct  was 
especially  difficult  to  empty  of  its  three  or  four  stones.  After  this 
normal  bile  welled  up  from  the  gall-bladder.  With  constant  drainage 
and  removal  of  all  stones  the  patient  made  an  excellent  recovery  and 


ABDOMINAL   AND    OTHER   TUMORS 


119 


left  the  hospital  on  the  2gth  of  August.  A  year  later,  September  4, 
1912,  the  patient  reported  entirely  free  from  pain,  jaundice,  or  other 
symptoms  pointing  to  the  biliary  tract. 

Case  36 

A  housewife  of  fifty-four  entered  the  hospital  August  8,  191 1. 
There  was  nothing  of  interest  in  her  family  history.  She  had  "grip" 
a  year,  and  again  six  months,  ago.  She  has  had  twelve  children  and 
one  miscarriage. 

For  ten  years  she  has  had  occasional  brief  attacks  of  cramp-like 
pain  in  the  left  side  of  the  abdomen,  but  it  has  never  been  severe  and 


Fig-  S3- — Tumor  felt  in  Case  36. 


has  never  troubled  her  much.  Two  years  ago,  after  the  menopause, 
she  began  to  lose  flesh,  and  then  noticed  a  large,  hard  lump  in  the  left 
hypochondrium.  This  lump  has  increased  in  size  since  then,  and  the 
cramps  in  the  same  region  have  become  more  frequent  and  more 
severe,  sometimes  shooting  across  to  the  right  side  of  the  abdomen  or 
into  the  left  flank  and  back.  This  pain  lasts,  however,  but  a  few 
minutes,  though  there  is  a  heavy,  dragging  sensation  in  the  same 
region  most  of  the  time.  Since  the  menopause,  two  years  ago,  she 
has  lost  50  pounds  and  considerable  strength.     Her  appetite  is  good. 


I20  DIFFERENTIAL  DIAGNOSIS 

She  has  no  mdigestion  or  vomiting,  and  though  her  bowels  are  con- 
stipated she  has  never  had  to  stop  work. 

For  sixteen  years  she  has  noticed  that  her  urine  is  turbid  and 
milky  in  appearance,  but  it  has  never  caused  any  pain  or  been  passed 
with  abnormal  frequency  or  in  abnormal  amount.  She  passes  it  once 
in  the  night. 

Physical  examination  is  negative  save  as  relates  to  the  abdomen, 
where  in  the  left  upper  quadrant  a  hard,  rounded  mass  is  felt,  dull 
on  percussion,  extending  under  the  left  costal  margin,  slightly  tender, 
immovable  with  respiration  or  under  pressure  (Fig.  53).  The  in- 
flated colon  traverses  this  lump.  Apparently  it  has  a  sharp  edge 
and  a  notch  on  the  inner  side.  The  urine  averages  35  ounces  in 
twenty-four  hours;  specific  gravity,  1016;  a  sediment  estimated  at  4 
per  cent,  pus  (by  volume). 

Discussion. — When  a  patient  has  had  a  turbid  urine  for  sixteen 
years  and  a  left-sided  stomachache  for  ten  years — the  latter  finally 
associated  with  a  palpable  lump,  gradually  increasing  in  size  for  the 
past  two  years — one  can  hardly  help  suspecting  some  benign  disease 
of  the  kidney,  even  though,  as  in  this  case,  there  has  been  a  loss  of 
strength  and  of  much  weight — "50  pounds" — and  even  though  the 
palpable  mass  in  the  left  hypochondrium  has  a  sharp  edge  and  a 
notch.  The  latter  observation  would  tend  to  make  us  think  we  were 
dealing  with  a  splenic  enlargement,  but  against  this  is  the  presence  of 
a  demonstrable  pyuria;  also  the  fact  that  the  inflated  colon  traverses 
the  mass. 

In  view  of  the  facts  last  mentioned,  it  seems  to  me  clear  that  the 
proper  diagnosis  in  this  case  is  of  some  chronic  non-malignant  disease 
of  the  kidney.  The  pyuria  makes  it  very  probable  that  this  disease  is 
either  a  tuberculous  or  a  non-tuberculous  pyonephrosis.  Cystoscopy 
should  make  the  diagnosis  more  certain  and  give  us  a  material  with 
which,  through  pathologic  tests,  we  can  settle  the  question  of  a  tuber- 
culous or  a  non-tuberculous  lesion. 

Outcome. — Cystoscopy  showed  a  ribbon  of  pus  coming  from  the 
left  ureter,  especially  when  pressure  was  exerted  over  the  mass  in  the 
left  side.  The  right  ureter  was  catheterized  and  a  urine  of  normal  con- 
stituency obtained.  The  phthalein  test  showed  that  the  color  appeared 
in  nine  minutes.  Dr.  Hugh  Cabot  had  no  doubt  that  the  tumor  was 
a  pyonephrosis  and  that  the  right  kidney  would  support  life.  Twenty 
minims  of  the  sediment  from  the  urine  were  injected  into  a  guinea-pig 
August  13th.  Autopsy  on  this  pig  September  20th  showed  nothing 
abnormal.     Bacteriologic  examination  of  the  urine  from  the  right 


ABDOMINAL  AND    OTHER   TUMORS  121 

ureter  showed  no  growth.  The  leukocytes  numbered  7500;  hemo- 
globin, 75  per  cent.  In  ten  days'  observation  the  temperature  rarely 
rose  above  99°  F.     The  systolic  blood-pressure  was  1 20. 

Operation,  October  17th,  showed  a  great  deal  of  dense,  inflamma- 
tory tissue  beneath  the  costovertebral  angle.  With  great  difficulty  the 
kidney  was  dissected  free  from  the  inflammatory  mass  above  described. 
This  mass  was  so  gristly  that  a  sharp  pair  of  heavy  scissors  were 
necessary  to  dissect  the  kidney  free. 

The  pathologist's  examination  may  be  summed  up  as  follows: 
The  kidney  measured  14  by  12  cm.  On  section  it  was  filled  with  pus 
and  contained  many  abscess-cavities  surrounded  by  fibrous  and  fatty 
tissue.  In  one  portion  there  was  a  large  branching  stone,  firmly 
embedded  in  the  kidney  substance.  Microscopic  examination  showed 
no  recognizable  kidney  structure. 

Case  37 

An  unoccupied  American  girl  of  eighteen,  who  has  always  lived 
in  New  England,  entered  the  hospital  October  27,  1908.  The  patient 
was  recommended  to  the  hospital  by  Dr.  W.  M.  Conant  for  relief  of 
an  epigastric  tumor.  Two  sisters  and  one  brother  have  died  of  tuber- 
culosis of  the  lungs.  The  parents,  two  sisters,  and  three  brothers  are 
Hving  and  well.  Her  menstruation  began  at  twelve  years  and  was 
regular  for  the  first  six  months.  Since  then  it  has  been  very  irregular, 
the  intervals  varying  from  two  to  seven  weeks.  At  the  time  of  the 
period  or  just  before  it  she  notices  sharp  pain  in  the  region  of  her 
epigastric  tumor.  This  pain  lasts  until  she  has  finished  menstruation. 
The  pain  radiates  to  the  region  of  the  spleen.  She  has  had  a  little 
intermenstrual  flowing,  lasting  from  one-half  to  one  hour,  coming 
perhaps  once  a  week.  With  this  flow  there  is  also  pain  in  the  region 
of  the  tumor. 

The  tumor  above  referred  to  has  been  noticed  for  about  three 
years,  but  the  patient's  pain  has  troubled  her  much  longer.  In  the 
past  three  years  the  mass  has  been  gradually  enlarging,  especially  in 
the  last  five  months,  and  with  its  growth  it  has  become  more  painful, 
until  now  it  is  associated  with  a  constant  dull  ache  and  with  pains 
darting  to  the  left.  There  have  been  occasional  attacks  of  vomiting 
both  before  and  since  the  time  at  which  this  tumor  was  discovered. 
These  attacks  are  not  now  more  frequent  than  they  were  three  years 
ago.  They  usually  come  about  three  hours  after  eating  and  the- ex- 
pelled fluid  is  green  and  frothy.  The  bowels  are  regular.  A  small 
amount  of  food  satisfies  her;  any  more  causes  nausea.     She  has  never 


122  DIFFERENTLA.L    DLA.GNOSIS 

been  jaundiced.  She  thinks  of  late  she  has  been  losing  weight,  as  her 
clothes  seem  to  be  too  loose  for  her. 

Physical  examination  shows  excellent  nutrition,  normal  pupils, 
normal  chest,  sluggish  reflexes,  no  enlarged  glands. 

The  epigastrium  is  occupied  by  a  tumor  mass  of  the  size,  appar- 
ently, of  an  infant's  head.  It  is  symmetric,  save  at  the  costocartilagin- 
ous  junctions  of  the  sixth,  seventh,  and  eighth  ribs  on  the  left,  where 
there  is  a  smaller  swelling  about  the  size  of  a  hen's  egg.  The  larger 
tumor  mass  is  somewhat  soft.  The  smaller  one,  which  seems  to  be 
attached  to  the  ribs,  is  also  soft.  The  entire  left  lower  quadrant  is 
hyperresonant.  Light  percussion  over  the  larger  tumor  shows 
relative  dulness.  Heavy  percussion  gives  resonance.  Moderate 
pressure  on  the  epigastric  mass  ehcits  some  pain.  Vaginal  examina- 
tion is  negative.  The  inflated  colon  apparently  overlies  the  tumor. 
The  blood  and  urine  are  negative. 

During  most  of  her  three  weeks'  stay  in  the  hospital  the  patient's 
temperature  reached  99°  or  99.5°  F.  each  evening.  Twice  it  rose  a 
little  above  100°  F.  There  was  no  free  fat  in  the  stools.  The  Cam- 
midge  test  was  negative.  Dr.  F.  B.  Harrington  considered  the  case 
a  pancreatic  growth  and  advised  operation.  Dr.  Hugh  Cabot  con- 
sidered it  a  cyst,  connected  either  with  the  pancreas  or  the  mesentery, 
or  possibly  a  hydatid.  Dr.  Maurice  H.  Richardson  considered  it  a 
pancreatic  cyst  caused  by  impaction  of  a  stone  in  the  canal  of  Wirsung. 
Dr.  Wilder  Tileston  considered  it  a  phantom  tumor. 

Discussion. — From  reading  this  case  and  noting  especially  the 
long  duration  of  the  symptoms,  the  good  nutrition  of  the  patient, 
and  the  presence  of  a  large  tumor  near  the  Kver,  one's  first  thought 
might  easily  be  of  a  hydatid  cyst.  Against  this,  however,  is  the 
patient's  residence.  So  far  as  I  know,  up  to  the  present  time,  no  case 
of  hydatid  disease  originating  in  New  England  has  ever  been  re- 
ported.    Most  of  the  patients  that  I  have  seen  have  been  Greeks. 

The  strong  tuberculous  family  history  and  the  slight  fever  might 
make  us  conjecture  that  a  tuberculous  peritonitis,  producing  a  mass 
of  adherent  intestinal  coils,  has  caused  the  tumor,  but  I  have  never 
heard  of  a  tumor  so  large  as  this  in  tuberculous  peritonitis,  and  the 
absence  of  fever  is  against  it. 

The  situation  of  the  mass  favors  a  pancreatic  cyst,  but  we  have 
no  further  evidence  to  bolster  up  this  case.  Functional  tests  of  the 
pancreas  should  at  least  be  tried  before  any  such  diagnosis  is  made. 

On  the  2d  of  November  a  stomach-tube  was  passed,  with  the 
result  that  when  pressure  was  made  over  the  epigastrium  a  large 


ABDOMINAL  AND    OTHER   TUMORS  1 23 

amount  of  gas  was  expelled  through  the  tube  and  the  tumor  com- 
pletely disappeared.  The  stomach  was  then  inflated  and  found  to 
be  of  normal  size.  After  the  injected  air  had  been  again  expellee]  no 
tumor  could  be  felt,  but  after  withdrawal  of  the  tube  the  swelling 
immediately  reappeared;  :r-ray  examination  was  apparently  negative. 
On  the  3d  of  November  the  abdomen  was  opened,  but  absolutely 
nothing  abnormal  was  found  in  any  part  of  it.  The  patient  made  an 
uneventful  recovery  and  left  the  hospital  November  19,  1908. 

This  case  seems  to  me  of  special  value  because  we  were  not  con- 
tent in  seeing  the  tumor  disappear  after  the  passage  of  a  stomach- 
tube,  but  went  on  to  final  proof  through  exploratory  incision.  Just 
what  a  phantom  tumor  means  it  is  not  easy  to  say.  Doubtless  the 
swallowing  of  air  and  its  retention  in  the  stomach  is  the  most  import- 
ant element,  but  it  is  hard  to  see  how  this  air  can  remain  in  the  stomach 
throughout  the  processes  of  digestion. 

The  slight  fever  in  this  case  is  interesting  and  tends  to  prove  that 
we  may  have  fever  in  the  absence  of  all  known  pathologic  processes, 
the  so-called  neurotic  fever. 

Case  38 

A  reed-chair  maker  of  thirty-eight  entered  the  hospital  March  6, 
191 2.  His  family  history  and  past  history  are  not  of  special  interest. 
The  patient  occasionally  goes  off  on  a  spree,  perhaps  three  times  a 
year.  On  these  occasions  he  drinks  mostly  beer.  Otherwise  his 
habits  are  good.  Four  months  ago  he  began  to  have  attacks  of  pain 
in  his  right  hip,  knee,  or  ankle,  the  pain  shooting  from  one  point  to  the 
other  and  lasting  from  four  to  eight  hours,  gradually  subsiding.  Up 
to  four  weeks  ago  he  had  had  seven  of  these  attacks.  Each  of  them 
forced  him  to  quit  work  and  remain  quiet  for  two  or  three  days,  and 
each  attack  was  followed  by  numbness  in  the  leg  and  a  difficulty  in 
extending  it. 

Three  months  ago  he  first  noticed  a  painless  swelling  on  one  of 
his  right  ribs.  This  has  remained  stationary  in  size.  Four  weeks 
ago  he  observed  a  bulging  in  the  right  hypochondrium  and  a  con- 
stant slight  pain  there.  Both  have  steadily  increased.  For  three 
months  he  has  had  vomiting  attacks  two  or  three  times  a  week  and 
•ejected  moderate  amounts  of  greenish  fluid,  but  never  any  food  or 
blood.  His  bowels  have  required  cathartics  for  the  last  four  months, 
and  even  with  cathartics  he  often  goes  two  or  three  days  without 
movements.  He  has  noticed  nothing  abnormal  about  the  stools. 
He  has  never  been  jaundiced.     His  appetite  has  been  poor.     He  has 


124 


DIFFERENTIAL  DLA.GNOSIS 


had,  SO  far  as  he  knows,  no  fever.  Four  months  ago  he  weighed 
165  pounds,  now  167  pounds,  though  he  is  quite  sure  he  has  lost 
flesh.     He  has  done  no  work  for  four  weeks. 

Physical  examination  shows  a  marked  loss  of  subcutaneous  tissue. 
The  right  eye  is  missing.  The  left  pupil  is  slightly  irregular,  but  re- 
acts well.  Over  the  third  right  rib,  in  front,  is  a  firm,  nodular,  tender 
mass,  the  size  of  an  egg,  apparently  attached  to  the  rib,  but  not  to 


Fig.  54. — Signs  found  in  Case  38. 


the  overlying  skin.     The  condition  of  the  lungs  and  abdomen  is 
shown  in  Fig.  54. 

Save  for  slight  edema  of  the  ankles  the  extremities  are  negative. 
The  knee-jerks  obtained  only  on  reinforcement.  Blood-pressure, 
165  mm.  Hg,  systolic.  The  urine  at  entrance  seems  to  be  negative, 
but  is  somewhat  turbid.  There  is  no  Bence- Jones  albumose.  Red 
cells,  5,120,000;  white,  17,200  at  entrance,  24,400  March  8th.  Poly- 
nuclears,  80  per  cent.  Slight  achromia  of  the  red  cells,  hemoglobin 
70  per  cent.     Wassermann  reaction  negative.     Feces  negative.     The 


ABDOMINAL  AND    OTHER   TUMORS  1 25 

patient's  girth  over  the  most  prominent  part  of  the  epigastric  tumor 
is  98.5  cm.  Diagnosis  at  entrance  seemed  to  be  hypernephroma  or 
sarcoma  with  a  possibility  of  cyst,  involving  the  liver  or  pancreas. 
x-Ray  showed  the  diaphragm  very  high  on  both  sides  and  the  heart 
slightly  enlarged  on  the  left,  but  there  was  no  evidence  of  bony  in- 
volvement. The  right  eye  had  been  removed  three  years  previously 
after  an  injury  from  a  piece  of  steel. 

Discussion. — ^A  nodular  mass,  occupying  the  site  of  the  liver,  is 
the  most  important  fact  in  this  case.  Apparently  this  mass  has  ex- 
isted at  least  three  months.  Whether  or  not  it  is  connected  with  the 
sciatic  pains  which  appeared  a  month  earlier  we  caimot  say.  Pos- 
sibly those  pains  were  associated  with  the  patient's  alcoholism. 
Possibly  they  may  be  tabetic,  as  the  condition  of  the  pupils  and  knee- 
jerks  should  make  us  suspicious  of  a  latent  tabes,  although  the  Was- 
sermann  reaction  is  negative. 

The  presence  of  a  lump  over  one  rib  suggests  a  metastasis,  and 
makes  us  think  at  once  of  the  tumor  which  most  often  produces  bony 
metastasis,  namely,  hypernephroma.  It  is  not  at  all  impossible  that 
a  large  renal  tumor  might  push  forward  to  the  anterior  abdominal  wall, 
displacing  the  Hver  to  one  side,  but  such  occurrences  are  rare,  and  there 
is  nothing  in  the  urine  to  support  the  hypothesis  of  hypernephroma. 

The  lump  on  the  rib  might  be  a  myeloma,  though  such  tumors 
are  usually  multiple  and  are  usually  associated  with  the  Bence- Jones 
body  in  the  urine.  Only  histologic  examination  could  make  us  pos- 
itive on  this  point. 

Nodular  tumors  in  the  region  of  the  liver  should  always  make  us 
think  of  the  possibility  of  melanotic  sarcoma,  especially  if  the  patient 
has  had  anything  wrong  with  his  eye,  for  in  this  organ,  as  is  well  known, 
such  tumors  are  most  apt  to  originate.  Despite  the  positive  state- 
ment in  the  history  of  this  case  that  the  eye  was  removed  on  account 
of  trauma,  one  of  the  physicians  who  saw  the  patient  insisted  on  beUev- 
ing  that  we  were  dealing  with  a  melanotic  sarcoma  of  the  liver,  second- 
ary to  a  similar  growth  in  the  eye.  This  chain  of  reasoning  leads 
us  to  consider  the  possibility  of  finding  melanuria  in  the  urine.  Such 
a  test  should  certainly  be  made,  for  although  in  most  cases  the  dis- 
coloration of  the  urine  makes  itself  obvious,  this  is  not  always  so. 

Outcome. — Dr.  J.  H.  Wright  considered  the  growth  a  melanotic 
sarcoma,  originating  in  the  eye,  with  metastases  in  the  liver  and 
pectoral  region.  The  urine  was  examined  for  melanin  and  positive 
tests  obtained  March  9th  and  17th.  Syphihs  was  also  considered. 
On  the  9th  there  was  sHght  shifting  dulness  in  the  abdomen.     The 


126  DIFFERENTIAL  DIAGNOSIS 

tumor  over  the  rib  was  opened  and  found  to  consist  of  thin-walled 
capsule,  containmg  grayish,  grumous  material.  The  rib  surface  was 
eroded  and  the  sac  seemed  to  lead  up  between  the  ribs.  No  micro- 
scopic examination  is  recorded. 

The  patient  lost  ground  rapidly  and  died  on  the  2 2d.  There  was 
no  autopsy. 

Case  39 

A  suspender  maker  of  sixty- two  entered  the  hospital  June  25, 
IQ12.  The  patient  states  that  he  "had  the  pox  thirty  years  ago" 
and  has  had  a  group  of  pimples  every  summer  since.  About  two 
years  ago  he  first  noticed  an  easily  movable  lump,  the  size  of  a  hen's 
egg,  just  below  the  left  costal  border.  This  has  gradually  grown  to  its 
present  size,  without  producing  any  symptoms.  He  has  worked 
steadily,  but  five  weeks  ago,  while  lifting  a  trunk,  he  strained  him- 
self. Since  then  he  has  been  steadily  running  down.  The  mass  is 
now  tender  on  pressure  and  there  is  a  constant  dull  ache  in  it,  with 
occasional  attacks  of  sharp  pain  radiating  to  the  back  and  left  groin. 
The  pain  has  no  relation  to  food  or  to  the  passage  of  urine  or  feces. 
For  the  past  month  he  has  lost  much  weight  and  strength  and  is  now 
in  bed  much  of  the  time.  Appetite  is  poor;  bowels  move  every  one 
to  three  days.     He  has  noticed  nothing  abnormal  about  his  urine. 

Physical  examination  shows  moderate  emaciation,  many  acne 
papules  and  pustules,  mucous  membranes  slightly  cyanotic.  Inguinal 
glands  slightly  enlarged.  Chest  negative.  In  the  left  hj^ochondrium 
is  a  smooth,  hard,  rounded,  slightly  movable  tumor,  fidling  out  the 
flank  and  pushing  up  the  ribs.  Impulse  exerted  upon  it  is  felt  in  the 
left  lumbar  region.  The  inflated  colon  lies  between  the  tumor  mass 
and  the  abdominal  wall.  The  urine  shows  numerous  pus-cells  and  a 
good  deal  of  mucus,  no  blood.  The  blood  is  normal.  Blood-pressure, 
135  mm.  Hg.,  systolic;  80  mm.  Hg.,  diastolic.  No  fever  in  three 
days'  observation.     Wassermann  reaction  negative.     Feces  negative. 

Discussion. — In  view  of  the  syphilitic  history,  it  is  worth  ques- 
tioning, for  a  moment,  whether  the  lump  in  the  left  hypochondrium 
may  possibly  represent  a  gumma  of  the  left  lobe  of  the  Kver.  The 
negative  Wassermann  reaction  is  somewhat  against  this,  and  the 
large  mass  and  characteristic  situation  of  the  tumor  makes  it  much 
more  probable  that  we  are  dealing  with  a  kidney. 

Apparently  the  lump  has  existed  in  this  region  for  at  least  two 
years,  although  the  patient's  health  was  good  until  five  weeks  ago. 
It  is  not  at  all  probable  that  the  strain  mentioned  in  the  history  has 


ABDOMINAL  AND    OTHER   TUMORS  1 27 

anything  to  do  with  making  the  patient  run  down.  Presumably 
the  change  which  occurred  five  weeks  before  he  entered  the  hospital 
was  not  due  to  any  external  cause,  but  rather  to  the  natural  progress 
of  the  disease.  Our  behef  that  the  lesion  is  connected  with  the 
kidney  is  strengthened  by  the  fact  that  we  have  no  symptoms  refer- 
able to  the  other  organs  which  most  often  cause  symptoms  in  the  left 
hypochondrium,  viz.,  the  stomach,  the  spleen,  and  the  colon. 

Assuming,  then,  that  we  are  dealing  with  a  renal  tumor,  asso- 
ciated with  pus  in  the  urine,  pyonephrosis  is  the  first  thing  to  be 
considered.  The  absence  of  fever  and  leukocytosis  are  somewhat 
against  this  supposition.  It  is  also  unusual  to  encounter  a  case  of 
pyonephrosis  the  symptoms  of  which  originated  at  the  age  of  sixty. 
Nevertheless,  without  a  cystoscopic  examination,  we  cannot  exclude 
renal  suppuration. 

Against  renal  tuberculosis  the  same  reasons  just  given  hold  good, 
yet  this  disease  cannot  possibly  be  excluded  without  further  ex- 
amination. 

Renal  neoplasm  was  considered  the  most  probable  diagnosis  by  all 
those  who  saw  the  case.  The  absence  of  a  hematuria  does  not  mili- 
tate against  this  diagnosis,  as  blood  appears  in  the  urine  in  cases  of 
hypernephroma  only  when  the  growth  reaches  the  renal  pelvis. 

Outcome. — On  the  29th  the  abdomen  was  opened  and  a  tumor  the 
size  of  a  child's  head  presented  in  the  left  hypochondrium.  While 
removing  this  tumor  the  spleen  was  torn  and  there  was  a  considerable 
hemorrhage,  controlled  by  packing.  This  damage  was  so  great  that 
the  spleen  had  to  be  removed.  After  the  ether  was  removed  the 
patient  stopped  breathing,  but  promptly  began  again.  He  recovered 
well  from  the  ether,  but  died  on  the  4th  of  July.  Examination  of  the 
tumor  showed  it  to  measure  19  by  24  cm.,  with  a  smooth  surface. 
It  consisted  of  a  firm,  thick  capsule,  enclosing  a  putty-like  mass,  with 
a  large  amount  of  bloody  fluid.  Microscopic  examination  showed  a 
richly  cellular  tumor  with  numerous  large  necrotic  areas.  The  cells 
were  of  rather  small  size,  with  deeply  eosin-staining  protoplasm,  and 
deeply  staining  nuclei.  These  cells  were  embedded  in  firm,  fibrous 
tissue  and  had  a  papillary  arrangement  on  connective-tissue  stalks  of 
various  widths.  The  diagnosis  was  hypernephroma.  The  spleen  was 
normal. 

Case  40 

A  Greek  mill  hand  of  twenty-four,  born  in  Turkey,  was  seen 
November  10,  1913,  complaining  of  abdominal  pain.     Family  history, 


128 


DIFFERENTIAL   DIAGNOSIS 


past  history,  and  habits  negative.  In  the  past  three  months  he  has 
had  ten  attacks  of  colicky  umbilical  and  epigastric  pain,  with  vomiting 
at  a  variable  interval  after  meals.  Duration  usually  three  or  four 
hours;  last  ni;ght,  eight  hours.  The  pain  is  not  relieved  by  food, 
pressure,  or  posture.  Morphin  has  been  used  in  three  attacks. 
Vomiting  and  hot  applications  give  some  relief.  Vomitus  not  charac- 
teristic. Much  gas  after  food.  He  has  lost  much  weight  and  has 
done  no  work  for  three  months. 


Fig-  55- — Masses  felt  in  Case  40,  November  24,  1913.     The  same  Itmips  can  be  identified 
by  their  numbers  in  Fig.  56. 


On  physical  examination  a  hard  lump,  the  size  of  a  walnut  (Fig. 
55,  No.  i),  is  felt  to  the  right  of  and  below  the  navel.  In  the  vicinity 
of  the  descending  colon  is  another  mass  the  size  of  a  small  egg  (Fig. 
55,  No.  2).  Both  masses  at  times  disappear.  No  visible  peristalsis. 
Left  epididymis  slightly  thickened.  Pupils  normal.  Knee-jerks  absent. 
Other  reflexes  and  the  rest  of  visceral  examination  negative.  Guaiac 
test  positive  in  fasting  gastric  contents  and  after  test-meal.  Free  HCl 
absent.  No  stasis.  Six  stools  guaiac-negative.  Bismuth  a;-ray  showed 
a  small,  high  stomach,  with  irregular  peristalsis,  especially  at  lesser 


ABDOMINAL  AND    OTHER  TUMORS 


129 


curvature,  where  the  outline  also  shows  shortening  and  irregularity. 
Pyloric  sphincter  and  duodenal  cap  not  abnormal.  Bismuth  enemata 
gave  negative  results. 

Blood  and  urine  negative.  Wassermann  negative;  x-rscy  of  chest 
negative.  Blood-pressure  100,  systolic;  80,  diastolic.  Pulse,  tem- 
perature, and  respiration  normal  for  three  weeks'  observation.  Bowels 
move  well. 

Clinical  diagnosis:  Dr.  R.  I.  Lee,  Gastric  ulcer  of  lesser  curvature. 
Dr.  E.  A.  Codman,  Chronic  intussusception. 


Fig.  56. — Lumps  felt  December  i,  1913. 


November  24th  masses  are  felt  as  in  Fig.  55.  An  oil  enema  pro- 
duces a  tremendous  mass  of  feces.  November  25th  he  had  severe 
coHcky  pain  all  day,  with  hard,  distended  belly.  Morphin  and 
atropin  relieved  the  pain.  Masses  were  still  clearly  felt.  November 
27th,  after  test-meal,  free  HCl  c.04;  total  acidity  0.027;  guaiac  test 
positive.  On  the  28th  there  were  two  more  lumps  (Fig.  56,  Nos.  3 
and  4) .  Tuberculous  glands  was  the  diagnosis  most  considered,  with 
malignant  disease  second. 

Discussion. — A  great  many  diagnoses  were  considered  by  members 

Vol.  II— 9 


130  DIFFERENTIAL  DIAGNOSIS 

of  the  attending  staff  in  this  case.  At  the  beginning  of  his  hospital 
stay,  before  the  tumor  masses  had  made  themselves  obvious,  our 
chief  evidence  of  disease  was  the  x-vay  and  the  finding  of  blood  in  the 
stomach-contents.  From  these  facts  a  peptic  ulcer  was  suspected. 
Later,  when  the  tumors  have  made  their  appearance,  but  appeared 
to  be  curiously  fugitive — shifting  their  place  from  day  to  day — the 
idea  of  a  chronic  intussusception  was  entertained.  Earlier  still, 
the  colicky  epigastric  pain,  leading  to  the  use  of  morphin,  had  made 
us  consider  gall-stones. 

After  the  administration  of  the  oil  enema  and  the  evacuation  of  a 
very  large  amount  of  feces  the  question  of  fecal  impaction  was  con- 
sidered, although,  I  think,  wrongly.  I  have  yet  to  be  convinced  that 
fecal  impaction,  without  some  organic  disease  producing  a  previous 
intestinal  stenosis,  ever  produces  any  important  symptoms  or  tumors. 
Fecal  impaction  seems  to  me  largely  a  diagnostic  myth,  especially 
when  considered  as  a  possible  cause  of  intestinal  obstruction.  In  the 
vast  majority  of  cases  in  which  I  have  known  it  to  be  considered  in 
differential  diagnosis,  it  has  turned  out,  as  the  present  case  did,  to 
involve  some  very  different  diagnosis  as  the  true  one. 

Multiple  tuberculous  tumors,  due  to  adenitis  or  adherent  intes- 
tinal coils  (tabes  mesenterica),  was  the  diagnosis  made  by  the  major- 
ity of  those  who  saw  this  case.  It  was  almost  the  only  common 
disease  which  could  produce  such  an  assembly  of  lumps  as  finally 
made  themselves  felt. 

The  alternative  supposition  of  malignant  disease  was  also  upheld 
by  several  members  of  the  staff,  but  the  patient  seemed  hardly  sick 
enough,  and  few  of  us  had  seen  so  many  tumors  in  any  type  of  neo- 
plasm involving  the  intestine. 

Outcome. — December  i,  19 13,  he  was  transferred  to  the  Surgical 
Wards.  Meantime  he  had  been  home  and  had  secured  from  his 
attending  physician  a  diagnosis  of  "pyloric  stenosis."  Dr.  W.  N. 
Conant  first  made  diagnosis  of  tuberculous  peritonitis.  Under  ether 
the  lower  lump  (No.  i)  was  easily  felt,  and  was  so  hard  that  the  diag- 
nosis was  promptly  changed  to  malignant  disease  of  the  gut.  Inci- 
sion over  it  showed  this  lump  to  involve  the  intestine  and  adjacent 
mesentery.  The  lump  was  3  inches  long,  i^  inches  wide,  spool 
shaped.  The  bowel  above  it  was  thickened  and  dilated;  below  it, 
normal  (Fig.  56). 

In  the  splenic  region  another  tumor  (No.  2),  also  involving  the  gut, 
was  found.  It  was  as  large  as  the  fist,  hard  and  nodular.  In  handling, 
it  broke,  and  excision  was  necessary.     End-to-end  intestinal  anas- 


ABDOMINAL  AND    OTHER  TUMORS  I3I 

tomosis  was  done.  No.  i  was  side  tracked  by  a  lateral  anastomosis. 
No.  3  was  felt  in  the  left  inguinal  region,  but  was  not  connected  with 
gut.  Dr.  Whitney's  report  showed  a  round-cell  sarcoma  {i.  e.,  lympho- 
blastoma) . 

December  27th,  after  an  uneventful  convalescence,  the  patient 
went  home. 

Case  41 

A  Greek  of  twenty-two  entered  the  hospital  February  21,  1914. 
His  family  history  was  negative.  He  denies  venereal  disease.  Seven 
years  ago  he  felt  a  pain  and  non-tender  lump  in  the  right  side  of  belly, 
under  the  belt.  The  lump  disappeared  in  a  week  or  so.  Two  years 
ago  he  had  a  similar  attack  and  lump.  Four  and  a  half  months  ago 
he  had  headache,  "yellow  skin,"  fever,  and  nausea.  The  fever  left 
in  a  few  days.  At  this  time  he  felt  a  lump  in  the  right  upper  quadrant, 
not  tender,  not  constant.  The  "jaundice"  ceased  in  one  month. 
Soon  after  he  noted  pain  in  left  upper  quadrant,  worse  on  exertion, 
but  never  severe.  He  lost  some  strength,  but  kept  at  work  until 
a  week  ago,  when  he  gave  up  on  account  of  left-sided  pain  and  disten- 
tion. He  was  costive,  but  noticed  no  blood  or  tarry  stools.  Appetite 
and  sleep  good;  no  loss  of  weight. 

Physical  examination  showed  no  jaundice,  no  emaciation.  There 
was  a  scar  in  neck,  5  by  i  cm.  [From  this  point  a  mass  was  removed 
when  he  was  a  child.]  The  contour  of  the  right  lower  axilla  was 
slightly  more  full  than  the  left.  There  was  a  high-pitched  musical 
systolic  murmur  over  the  whole  precordia,  not  heard  in  the  axilla. 
The  first  sound  was  obscured  by  it.  The  pulmonic  second  was  greater 
than  the  aortic  second  and  double.  The  apex  shifted  3  cm.  with  change 
of  position.  There  were  three  nodules  on  the  Kver  edge  and  extend- 
ing over  its  surface,  which  was  not  tender,  and  moved  freely  with 
respiration  (Fig.  57).  There  was  an  extensive  scar  on  the  outer 
lower  right  leg,  just  below  the  knee.  Rectal  examination  showed 
above  the  prostate  an  irregular  nodular  mass,  2  to  3  cm.  in  diameter, 
projecting  into  the  rectum,  immobile,  and  attached  to  the  anterior 
wall.  The  "liver  mass"  extends  through  to  back.  It  did  not  feel 
Hke  a  cyst.  Dr.  W.  H.  Smith  made  a  prehminary  and  tentative  diag- 
nosis of  h3^ernephroma  or  liver  neoplasm,  but  the  home  officer 
records  that  the  patient  "Looks  too  well  nourished  for  mahgnant." 
Stomach-tube  examination  was  negative ;  a:-ray  was  negative.  Blood 
and  urine  negative.     Wassermann  negative. 

The  following  diagnoses  were  also  considered:    (i)  Distended  gall- 


132 


DIFFERENTIAL  DIAGNOSIS 


bladder;  (2)  cyst  or  tumor  of  kidney;  (3)  cyst  or  tumor  of  the  under 
part  of  right  lobe  of  hver.  Bismuth  x-ray  examination  of  the  stomach 
showed  "pressure  on  lesser  curvature  from  some  tumor  outside  digest- 
ive tract." 

February  27th  a  collargol  plate  showed  apparently  some  patho- 
logic process  in  right  kidney. 

]\Iarch  6th  the  record  states:  "He  has  had  no  pain  while  here. 
Weight  of  evidence  is  for  lesion  of  kidney." 


Fig.  57. — Masses  felt  in  Case  41. 

Discussion. — The  most  important  points  about  this  case  were  the 
following : 

The  occurrence  of  a  mass  in  the  right  hypochondrium,  known  to 
be  of  long  duration,  associated  with  good  nutrition,  in  a  Greek. 
Were  the  patient  older  and  of  the  other  sex,  his  history  of  jaundice 
and  pain  in  the  region  of  the  gall-bladder  would  have  made  it  neces- 
sary for  us  to  put  gall-bladder  disease  first  among  the  diagnostic  possi- 
bilities. Against  this,  however,  is  the  actual  condition  which  was  felt 
in  the  region  of  the  liver.  Unless  we  were  wholly  mistaken,  it  was 
a  sharp  edge  and  not  a  round  sac  which  we  felt  in  the  right  hypo- 
chondrium. 


ABDOMINAL  AND   OTHER   TUMORS  I33 

Supposing  that  we  were  correct  in  our  belief  that  a  nodular  enlarge- 
ment of  the  liver  existed,  there  are  really  but  three  reasonable  possi- 
bilities: first,  malignant  disease;  second,  syphilis;  third,  hydatid. 

The  patient  is  extraordinarily  young  for  cancer  of  the  liver.  He 
has  had  no  gastric  symptoms  such  as  usually  accompany  the  primary 
gastric  cancer,  from  which  the  liver  metastases  follow.  Moreover, 
this  patient's  nutrition  is  extraordinarily  good  for  so  serious  a  neo- 
plasm. 

Syphilis  cannot  be  excluded  and  the  absence  of  a  Wassermann 
reaction  does  not  rule  it  out.  We  cannot  say,  however,  that  we  have 
any  positive  evidence  of  such  disease  unless  the  presence  of  an  accom- 
panying splenic  tumor  is  so  regarded. 

Hydatid  is  suggested  by  the  patient's  race  and  by  his  good  nutri- 
tion, despite  the  presence  of  a  large  tumor.  Against  it  we  have  the 
lack  of  any  eosinophilia  and  the  general  rarity  of  the  disease  in  New 
England.  We  have  almost  ceased  to  look  for  the  classical  hydatid 
thrill  about  which  the  older  text-books  used  to  excite  us  so  much. 

Outcome. — Operation  showed  a  liver  studded  with  cysts,  whence 
scolices  were  obtained. 

In  view  of  all  the  facts  and  of  the  patient's  good  recovery,  there 
seems  no  good  reason  to  believe  that  there  is  any  disease  in  the  kidney 
or  in  the  region  of  the  prostate.  The  findings  recorded  in  these  organs 
are  regarded  as  errors. 


CHAPTER   II 

VERTIGO 

Vertigo,  or  the  disturbance  of  static  control,  cannot  be  defined 
in  purely  objective  terms.  We  cannot  deny  that  a  person  is  dizzy, 
even  if  we  cannot  see  him  stagger  or  verify  the  existence  of  nystagmus. 
Nevertheless,  such  objective  verifications  are  always  to  be  sought  for, 
especially  in  medicolegal  cases,  traumatic  neuroses,  etc.  As  a  pre- 
senting symptom,  vertigo  is  not  at  all  common.  Joseph  Collins^ 
states  that  among  425  neurologic  cases  of  all  types,  seen  by  him  in  the 
New  York  Neurological  Institute  during  1910,  only  22  complained  of 
vertigo,  in  the  sense  of  a  definite  disturbance  of  equihbrium.  He 
excludes  here  sensations  called  dizziness,  but  consisting  chiefly 
of  blurred  vision,  minute  black  spots  in  the  visual  field,  and  dis- 
agreeable sense  of  mental  confusion. 

PHYSIOLOGIC  VERTIGO 

(a)  Most  normal  individuals  occasionally  become  dizzy  if  they  look 
down  from  a  great  height  or  look  up  to  a  great  height,  or  if  they  spin 
round  rapidly,  as  in  waltzing  without  reversing.  A  certain  number 
of  people  become  dizzy  if  they  ride  backward  in  a  railroad  train  or  if 
they  watch  moving  objects,  such  as  a  waterfall,  a  snowstorm,  water 
flowing  under  a  bridge,  or  clouds  overhead. 

(b)  Probably  in  a  different  group  should  be  placed  the  occasional 
attacks  of  dizziness  on  suddenly  rising  from  a  stooping  posture  or 
suddenly  lying  down,  on  quickly  turning  the  head,  or  quigkly  looking 
at  the  ceiling. 

(c)  What  is  called  car-sickness  and  sea-sickness  are  probably  exag- 
gerations of  these  physiologic  types  of  vertigo. 

(d)  In  many  persons  the  passage  of  a  galvanic  current  through  the 
head  or  a  syringing  of  the  external  ear  with  hot  water  is  sufficient  to 
produce  dizziness,  without  there  being  any  organic  disease  present  or 
any  pathologic  sensitiveness  to  ordinary  stimuli. 

^  New  York  Medical  Record,  1912,  vol.  Ixxxi,  p.  1019. 
134 


Causes  of  Vertigo 


AURAL  DISEASE 
ARTERIOSCLEROSIS 

OTHER  ORGANIC  BRAIN   DISEASE  NOT    NOTED  BELOW 

j 
THE   MENOPAU$E 

ACUTE  INFECTIOUS  DISEASE  (ONSET) 

NEUROTIC    STATES    (NEURASTHENIA,    HYSTERIA,    MI- 
GRAINE) 

OCULAR  DISEASE 

ANEMIA  ■■■■■■^■■■■^^■H 

HEART  DISEASE  ^HIHBHi^H^^^HIil^Hl 

TABES 

EXOPHTHALMIC  GOITER 

CEREBRAL  TUMOR 

EPILEPSY 

CEREBELLAR  TUMOR 

MULTIPLE  SCLEROSIS 


CASES  TOO  MANY  AND 
TOO  VAGUELY  ENU- 
MERABLE  FOR 
GRAPHIC  REPRE- 

SENTATION. 


952 
631 
172 
129 
121 
108 
28 
20 


CEREBRAL  AND  CERE- 
BELLAR ABSCESS 


135 


136  DIFFERENTIAL  DIAGNOSIS 

PATHOLOGIC  VERTIGO 

Dizziness,  as  a  result  of  disease,  may  be  divided  into  four  main 
groups : 

Vertigo  from  organic  brain  disease. 

Labyrinthine  vertigo  ("aural"). 

Vertigo  in  neurotic  patients. 

Vertigo  from  cerebral  anemia  or  transitory  cerebral  intoxication. 

In  a  general  way  we  may  say  that  the  dizziness  of  young  people  is 
ordinarily  transient  and  unimportant;  that  the  dizziness  of  elderly 
people  is  apt  to  be  recurrent  and  serious  because  it  usually  depends 
upon  organic  disease  of  the  brain  or  internal  ear.  Each  of  these  main 
groups  will  now  be  discussed  more  in  detail. 

Vertigo  from  Organic  Brain  Disease 

In  organic  brain  disease  we  must  distinguish,  as  the  commonest 
of  all  causes  of  vertigo,  arteriosclerosis.  When  an  elderly  person 
begins  to  have  attacks  of  vertigo,  we  may  usually  make  a  correct 
guess  that  it  is  due  to  arteriosclerosis.  These  attacks  may  be  mild 
and  occur  off  and  on  for  years  without  ushering  in  anything  more 
serious;  but  in  many  cases  they  are  either  the  beginning  or  the  pre- 
cursor of  apoplectic  seizures.  It  seems  to  me  impossible  to  distinguish 
the  vertigos  of  cerebral  syphilis,  so  called,  from  those  of  arteriosclerosis, 
just  described. 

In  cerebral  tumor,  vertigo  is  a  frequent  symptom,  especially  if  the 
growth  involves  the  frontal  lobes  or  the  cerebellum.  The  best  authori- 
ties find  vertigo  in  almost  every  case  of  cerebellar  disease,  in  the  major- 
ity of  frontal  tumors,  and  in  not  more  than  one-third  of  the  tumors 
occupying  other  parts  of  the  brain.  Cerebellar  vertigo  tends  to  be 
associated  with  staggering  or  swaying  in  one  particular  direction. 
According  to  Hitzig,  paroxysmal  attacks  of  vertigo  in  brain  tumor 
tend  to  prove  that  the  growth  is  in  the  regions  of  the  motor  areas. 

In  multiple  sclerosis  there  is  probably  no  more  constant  symptom 
than  vertigo.     Three-fourths  of  the  best  studied  cases  show  it. 

In  dementia  paralytica,  vertigo  is  common  as  an  early  symptom, 
before  the  disease  is  fully  developed.  Later  in  the  course  of  the  dis- 
ease it  always  appears  a  few  minutes  or  hours  before  an  acute  seizure 
(coma,  convulsion,  hemiplegia). 

Before  cerebral  hemorrhage  or  acute  softening,  vertigo  is  one  of 
the  commonest  of  prodromata.  It  is  distinctly  commoner  than 
headache. 


VERTIGO  137 

Aural  Vertigo 

A  patient  may  have  advanced  disease  of  the  ear  and  deafness, 
without  vertigo,  in  case  the  labyrinth  is  not  in  any  way  affected. 
Nevertheless,  in  the  vast  majority  of  affections  of  the  ear,  with  or 
without  deafness,  vertigo  is  a  more  or  less  common  symptom.  The 
complex  of  symptoms,  known  as  Meniere's  disease,  is  not  properly  a 
disease.  It  may  occur  without  any  organic  lesion  of  the  vestibule  or 
of  any  other  part  of  the  body.  In  the  latter  cases,  for  example,  in 
traumatic  neurosis,  one  may  use  the  term  pseudo-Meniere's  disease, 
but  this  seems  to  me  foolish.  The  complex  of  symptoms  usually 
associated  with  Meniere's  name  is  deafness,  tinnitus,  vertigo,  and 
nausea  or  vomiting,  the  whole  group  appearing  with  alarming  sud- 
denness and  often  utterly  prostrating  the  patient.  Less  constant  are 
the  sense  of  pressure  in  the  head,  nystagmus,  ataxia  of  the  cerebellar 
type,  and,  rarely,  diarrhea.  In  all  cases  of  this  type  the  help  of  an 
aurist  should  be  sought,  although  a  treatment  directed  to  the  ear  is 
often  unavailing. 

To  determine  whether  the  labyrinth  is  actually  involved  and  is  the 
cause  of  vertigo  the  general  practitioner  is  rarely  sufficiently  expert, 
and  a  speciaHst  should  be  consulted.  It  may  be  said,  however,  that 
labyrinthine  vertigo  can  rarely  be  diagnosed  unless  nystagmus  can  be 
observed.  On  the  other  hand,  it  must  not  be  forgotten  that  nystag- 
mus sometimes  occurs  spontaneously  and  habitually  in  otherwise 
healthy  people.  When  nystagmus  can  be  produced  by  spinning  the 
patient  upon  a  rotary  stool  or  by  hot  ear  injections,  labyrinth  disease 
is  much  more  strongly  suggested. 

Neurotic  Vertigo 

Whatever  else  we  may  or  m^  not  mean  by  the  neurotic  state 
(neurasthenia,  psychoneurosis,  congenital  nervousness),  it  certainly 
involves  an  undue  sensitiveness  to  stimuli  and  impressions  of  all  sorts. 
Most  cases  of  neurotic  vertigo  occur  when  a  p^on  is  exposed  to  some 
sudden  change  of  position  or  to  some  other  environment  which  in 
ordinary  persons  would  not  be  sufficiently  strange  to  upset  their  static 
control.  Thus,  in  many  neurotics,  especially  in  traumatic  neuroses, 
sudden  turnings,  bendings,  any  associations  with  the  conditions  which 
have  produced  the  original  injury,  walking,  driving,  and  other  common 
acts,  are  sufi&cient  to  produce  giddiness.  Especially  common  in  the 
neurotic  is  giddiness  or  headache  on  exposure  to  the  sun.  Many  of 
the  cases  of  vertigo,  supposedly  due  to  alcoholism,  to  tobacco,  or  to 


138  DIFFERENTL\L  DIAGNOSIS 

indigestion,  are  probably  of  the  neurotic  type.  In  this  form  of  vertigo 
there  are  often  no  objective  manifestations,  no  staggering  or  nystag- 
mus. If  the  patient  does  stagger  at  all,  it  is  usually  an  unsystematic 
lurching,  without  any  constant  tendency  to  go  to  one  side.  Patients 
with  neurotic  vertigo  almost  never  fall,  and  in  this  respect  their 
troubles  contrast  sharply  with  those  occurring  in  arteriosclerotics  and 
in  other  forms  of  organic  brain  disease.  In  the  latter,  serious  injury 
not  infrequently  results  from  a  fall  during  an  attack  of  vertigo. 

In  the  neurotic  type  of  vertigo  the  symptom  is  often  associated 
with  or  initiated  by  fear  and  autosuggestion.  Thus,  the  neurotic 
often  suffers  from  vertigo  when  he  gets  into  a  large  open  space,  and  in 
such  cases  his  dizziness  may  be  associated  with  or  substituted  for  an 
agoraphobia.  Conversely,  the  neurotic  is  often  dizzy  in  enclosed 
places,  in  church,  at  the  theater,  and  here,  again,  his  giddiness  is 
associated  with  fear  and  the  senseless  dread  that  he  cannot  get  out. 
Autosuggestion  plays  a  large  part  in  both  the  last-named  types  of 
vertigo,  but  there  is  another  element — an  ocular  element — in  many 
cases.  In  these  the  dizziness  seems  to  be  associated  with  inabihty  to 
fix  or  focus  the  eyes  upon  any  point  near  at  hand.  Sometimes  this 
weakness  is  transferred  wholly  into  the  psychic  field,  and  the  patient 
is  dizzy  because  he  cannot  concentrate  his  mind  upon  any  single 
point. 

Vertigo  in  Connection  with  Epilepsy. — With  epilepsy,  as  with  all 
acute  cerebral  seizures,  any  type  of  vertigo  may  occur,  either  as  a 
prodromal  symptom,  ushering  in  the  attack,  or  as  a  supposed  equiva- 
lent for  the  convulsive  attack.  The  great  majority  of  epileptics  are 
conscious  of  such  troubles  more  or  less  frequently. 

Vertigo  from  Disturbed  Cerebral  Circulation. — In  the  vasomotor 
disturbances,  at  the  time  of  the  menopause,  vertigo  is  often  asso- 
ciated with  flushing,  heat,  and  sweating  about  the  head.  Here  it  is 
natural  to  assume  that  the  dizziness  results  from  cerebral  hyperemia. 
Very  possibly  a  good  deal  of  the  giddiness  associated  with  cardiac 
disease  is  also  of  this  type,  though  it  may  belong  to  the  group  of  cases 
next  to  be  mentioned. 

Cerebral  anemia ^  either  in  the  form  associated  with  fainting  or  in 
that  which  forms  a  part  of  a  general  anemia,  as  in  chlorosis  or  after 
hemorrhage,  is  a  frequent  and  familiar  source  of  vertigo.  In  this, 
as  in  all  other  types  of  dizziness,  the  symptom  may  be  associated  with 
nausea,  pallor,  and  loss  of  consciousness. 


VERTIGO  139 

IS  THERE  A  GASTRIC  FORM  OF  VERTIGO? 

Thirty  years  ago  I  suppose  that  the  majority  of  cases  of  vertigo 
would  have  been  explained  as  resulting  from  stomach  trouble  (vertigo 
a  stomacho  Icdso).  Nowadays  we  are  very  skeptical  about  these  cases. 
The  more  carefully  they  are  studied,  the  fewer  of  them  appear  to  be 
of  gastric  origin.  Thus,  Charles  G.  Stockton^  reports  that  out  of  828 
patients  treated  by  him  for  stomach  trouble,  55  complained  of  vertigo, 
"but  in  30  of  these  the  symptom  was  traced  to  aural  defect,  renal  dis- 
ease, or  arteriosclerosis.  In  15  it  was  dependent  upon  neurasthenia, 
intoxication,  circulatory  disease,  or  gout.  Only  in  10  did  the  dizzi- 
ness appear  to  arise  from  dyspepsia,"  and  even  these  were  more  or  less 
doubtful.  In  Gower's  text-book  the  author  conjectures  that  not 
more  than  5  per  cent,  of  the  cases  of  vertigo  are  of  gastric  origin. 

It  is,  of  coui-se,  well  known  that  vertigo  is  very  frequently  associ- 
ated with  nausea,  vomiting,  and  other  gastric  symptoms,  but  in  the 
great  majority  of  cases  in  which  this  association  is  found,  the  dizziness 
arises  from  the  same  cause  that  produces  the  nausea,  as,  for  example, 
in  sea-sickness,  car-sickness,  brain  tumor,  syncope,  etc. 

Vertigo  of  reflex  origin — for  example,  the  so-called  laryngeal  ver- 
tigo— ^is  subject  to  a  good  deal  of  skepticism  by  the  most  competent 
authorities.  Many  of  the  cases  of  laryngeal  vertigo  are  associated 
with  a  violent  cough,  and  this,  with  cerebral  congestion,  would  bring 
them  into  the  same  general  group  with  the  vertigos  of  the  menopause. 

The  same  skepticism  exists  with  regard  to  the  majority  of  so-called 
toxic  vertigos,  such  as  those  from  tobacco  or  alcohol.  Circulatory 
influences  can  rarely  be  excluded,  and  if  the  dizziness  is  of  more  than 
transitory  occurrence  some  organic  basis  may  usually  be  found. 

In  conclusion,  it  may  be  said  that  the  great  majority  of  cases  of 
severe  chronic  or  paroxysmal  vertigo  are  found,  if  carefully  studied, 
to  have  involved  some  disease  of  the  labyrinth. 

Case  42 

An  Irish  hostler  of  thirty-one  entered  the  hospital  October  26, 
1900.  The  patient  has  always  used  tobacco  to  excess,  but  has  felt 
perfectly  well  until  yesterday  morning,  when  he  got  up  feeling  very 
dizzy  and  unable  to  walk  straight.  Vomiting  of  bitter,  green  fluid 
soon  followed.  After  that  he  managed  to  do  his  work  as  a  hostler, 
but  this  morning  the  symptoms  recurred  and  were  so  severe  that  he 
came  to  the  hospital  in  the  afternoon.  He  has  noticed  a  dazzling  of 
vision  for  two  days,  but  has  no  headache  and  no  other  complaints. 

^  New  York  Journal  of  Medicine,  August,  1912,  p.  416. 


I40  DIFFERENTLA.L   DIAGNOSIS 

At  entrance  his  temperature  and  respiration  were  normal.  His 
pulse  was  50,  and  during  his  ten  days'  stay  in  the  hospital  it  ranged 
between  50  and  60.  He  had  a  very  marked  polyuria  throughout: — on 
the  28th,  125  ounces;  on  the  29th,  165  ounces;  thereafter  in  the  vicinity 
of  100  ounces  a  day.  The  specific  gravity  varied  from  ico8  to  1017. 
Albumin  was  always  present  in  traces,  and  the  sediment  showed  a 
rare  hyalin  and  granular  cast,  with  small,  round  cells  and  fat  adher- 
ent; also  an  occasional  fatty  cast.  The  fundus  ocuH  was  normal. 
There  was  marked  nystagmus.  Below  the  right  scapula  breathing, 
voice  sounds,  and  percussion  resonance  were  diminished.  The  heart 
was  not  enlarged.  The  pulses  were  of  high  tension.  Aortic  second 
sound  very  sharp.     The  blood-pressure  not  measured.     No  edema. 

By  the  first  of  November  he  was  much  better,  had  no  dizziness  or 
gastric  symptoms,  and  felt  as  well  as  before  the  present  trouble. 
The  tension  of  the  pulse  was  less  high.  The  night  amount  of  urine 
never  exceeded  the  day  amount  until  the  last  two  days  of  his  stay, 
when  the  figures  were  as  follows:  November  i,  day,  34;  night,  78. 
November  2d,  day,  38;  night,  60.  He  left  the  hospital  on  the  4th  of 
November. 

Discussion. — In  the  hospital  record  of  this  case  the  vertigo  is 
attributed  to  the  use  of  tobacco,  but  from  my  study  of  the  record  it 
seems  to  me  clear  that  tobacco  had  little,  if  anything,  to  do  with  it. 
In  fact,  I  doubt  whether  tobacco  ever  produces  vertigo  except  in  a 
novice.  Although  we  lack  several  pieces  of  information  which  in  a 
more  modern  record  would  be  present,  viz.,  a  blood-pressure  measure- 
ment and  further  functional  tests  of  the  kidney,  I  feel  no  doubt  that 
the  vertigo  in  this  case  was  due  to  a  chronic  nephritis  with  hjq^er- 
trophied  and  dilated  heart.  In  such  disease  it  is  well  known  that 
cerebral  seizures  of  various  kinds  and  of  various  degrees  of  severity 
are  common,  and  whether  or  not  Pal's  idea  of  a  vascular  spasm  is  the 
correct  explanation  of  these  seizures,  the  important  fact  is  their 
constant  association  with  chronic  nephritis  and  hypertension,  with  or 
without  arteriosclerosis  of  the  cerebral  arteries. 

I  have  searched  the  hospital. records  diligently  for  a  more  plausible 
case  of  vertigo  due  to  the  use  of  tobacco,  but  this  is  the  best  that  I 
have  been  able  to  find,  and,  to  my  thinking,  the  vertigo  is  in  this  case 
certainly  due  to  the  condition  of  the  renal  and  vascular  systems. 

Case  43 

A  housewife  of  fifty- two  entered  the  hospital  March  27,  1902. 
Three  years  ago  the  patient  had  a  bad  fright  and  became  very  dizzy ,^ 


VERTIGO  141 

SO  that  she  had  to  lie  down  to  prevent  fainting.  Since  then  she  has  had 
similar  attacks  of  vertigo  about  once  a  month,  relieved  by  lying  down. 
Since  last  November,  however,  these  attacks  have  been  more  frequent 
and  now  occur  four  or  five  times  a  day.  Of  late  they  have  been  asso- 
ciated with  dyspnea  and  palpitation,  but  are  still  relieved  by  lying 
down  for  five  or  ten  minutes. 

For  several  months  she  has  noticed  pain  in  the  lower  abdomen  and 
the  small  of  the  back,  especially  after  exertion,  accompanied  by  fre- 
quency of  micturition.  She  passes  urine  twice  in  the  night.  Since 
November  she  has  had  more  or  less  hoarseness,  aggravated  by  ex- 
citement, and  steadily  increasing  of  late. 

On  further  questioning,  she  remembered  that  three  winters  ago 
she  had  neuralgia  in  the  upper  part  of  her  back,  across  the  shoulders, 
in  the  nape  of  the  neck,  and  in  the  right  hand.  These  attacks  have 
recurred  each  winter  and  are  associated  with  tenderness  of  the  pain- 
ful areas,  but  not  with  any  redness  or  swelling.  The  attacks  usually 
last  about  two  months.  She  had  one  child  born  thirty-three  years 
ago;  no  miscarriage.  All  her  life  she  has  been  more  or  less  troubled 
by  dyspnea  and  palpitation  on  exertion. 

Her  mother  died  at  fifty-five  of  consumption.  She  has  also  lost 
three  brothers  and  two  sisters  of  consumption.  Three  other  sisters 
and  two  other  brothers  are  living  and  well. 

Physical  examination  showed  good  nutrition,  moderate  cyanosis, 
normal  pupils,  glands,  and  reflexes.  At  the  left  apex  behind  there 
was  a  slight  dulness,  with  high-pitched  expiration,  increased  whisper, 
and  decreased  tactile  fremitus.  Otherwise  the  lungs  were  normal. 
The  heart's  apex  was  in  the  fifth  interspace,  5^  inches  from  the  median 
line,  the  right  border  2^  inches  from  median  fine.  There  was  well- 
marked  pulsation  at  the  junction  of  the  clavicle  and  sternum  on  the 
right  side,  and  considerable  bulging  of  the  clavicle  and  supraclavicular 
space.  The  veins  of  the  upper  sternal  region  were  prominent.  At 
the  apex  there  was  a  slight  systolic  and  a  loud  diastolic  murmur, 
with  absence  of  the  second  sound.  At  the  base  the  first  sound  was 
replaced  by  a  blowing  systolic  murmur  and  there  was  also  a  faint 
diastolic  murmur.  Over  the  seat  of  pulsation,  below  the  right  clav- 
icle, was  a  loud,  blowing  systolic  murmur  and  a  slight  systolic  shock. 
The  abdomen  was  negative.  Both  tibiae  were  nodular  and  there  was 
slight  edema  over  them.  The  pulse  was  not  obtained  in  the  left 
wrist.  Blood  and  urine  normal.  Tracheal  tug  present.  No  fever  in 
a  week's  observation. 

Discussion. — Although  this  patient  has  a  strong  tuberculous  his- 


142  DIFFERENTIAL  DIAGNOSIS 

tory,  there  are  no  actual  symptoms  in  the  case  which  we  can  attrib- 
ute to  a  tuberculous  lesion,  and  presumably  the  patient  has  not  been 
infected  in  any  important  degree. 

In  working  our  way  into  the  case  it  is  important  to  note  that  the 
attacks  of  vertigo  are  associated  with  dyspnea  and  with  a  condition 
in  which  the  patient  nearly  faints.  Vertigo  of  cardiac  origin  is  not 
at  all  infrequent,  and  such  an  origin  is  suggested  by  this  patient's 
dyspnea,  though  the  force  of  the  suggestion  is  weakened  when  we 
read  her  statement  that  she  has  had  dyspnea  more  or  less  all  her 
Hfe. 

After  reviewing  the  physical  signs  in  the  case,  the  bulging  and 
pulsation  at  the  right  sternoclavicular  joint,  the  diastoUc  murmur, 
with  absence  of  the  aortic  second  sound,  the  nodes  upon  the  shin- 
bones,  the  absence  of  the  left  pulse,  and  the  presence  of  a  tracheal 
tug,  we  can  have  little  doubt  that  the  patient  has  an  aneurysm  of  the 
aortic  arch,  and  that  her  hoarseness,  her  neuralgia  of  the  shoulder^ 
nape  and  hand,  and  probably  her  dyspnea,  are  due  to  the  same  cause. 
That  cause,  s>^hilis,  has  probably  produced  also  changes  in  the  cere- 
bral arteries,  whereby  the  amount  of  blood  passing  through  them  does 
not  vary  as  it  should,  according  to  the  demands  of  the  moment. 
One  can  well  conjecture  that  such  vascular  changes  would  produce 
vertigo. 

Outcome. — The  patient's  rest  in  bed  seemed  to  do  her  much  good. 
By  the  30th  she  was  very  anxious  to  get  home.  No  medication  was 
given  save  an  occasional  counterirritant  or  hypnotic,  and  on  the  3d 
of  April  she  left  the  hospital. 

Case  44 

A  druggist  of  fifty-eight  entered  the  hospital  December  8,  1902. 
The  patient  was  always  perfectly  well  until  last  July,  when,  after  a 
hearty  dinner,  he  became  dizzy  and  could  not  talk.  This  passed  off 
in  a  few  minutes  and  he  has  felt  well  until  yesterday,  when  the  same 
symptoms  recurred  and  were  followed  by  suffocation  and  soon  after 
by  unconsciousness. 

For  two  years  he  has  noticed  that  he  had  to  rise  twice  in  the  night 
to  pass  urine,  and  last  summer  he  had  one  short  spell  of  vomiting  and 
diarrhea.     His  eyesight  has  been  excellent. 

Physical  examination  showed  good  nutrition,  partial  coma,  pallor, 
and  a  peculiar  odor  to  the  breath,  not  urinous,  a  high-tension  pulse, 
a  sharp  aortic  second  sound,  marked  pulsation  of  the  brachials, 
visible  throughout  the  whole  arm.     There  was  no  paralysis.     At  the 


VERTIGO 


143 


apex  of  the  heart  a  soft  systolic  and  a  blowing  diastolic  murmur  was 
heard.  No  enlargement,  however,  of  the  organ  was  made  out.  The 
pulses  had  a  Corrigan  quality.  The  bladder  reached  to  the  umbilicus 
and  42  ounces  were  withdrawn  by  catheter.  The  rectal  temperature 
was  101°  F.  (Fig.  58).  The  leukocytes  were  14,500;  hemoglobin, 
75  per  cent.  The  urine  was  40  ounces 
in  twenty-four  hours;  specific  gravity, 
1009  to  1012;  albumin,  from  f  to  i  per 
cent.;  a  few  hyaline  and  highly  refrac- 
tive casts. 

Discussion. — When  vertigo  is  associ- 
ated with  aphasia  in  a  man  of  fifty- 
eight,  and  especially  when  six  months 
later  these  same  symptoms  are  followed 
by  an  attack  of  coma,  there  is  little 
doubt  that  we  are  dealing  with  cerebral 
arteriosclerosis.  The  history  of  noc- 
turia makes  it  probable  that  further 
examination  of  the  heart  and  kidney 
would  reveal  similar  arteriosclerotic 
changes  in  these  organs.  Unfortun- 
ately, we  have  no  blood-pressure  meas- 
urements, as  in  1902  we  were  not 
making  them  in  all  cases,  but  it  seems 
to  me  clear  that  the  coma  which  led  to  his  becoming  a  hospital 
patient  was  of  the  type  associated  with  a  chronic  nephritis  and 
cerebral  arteriosclerosis. 

Since  the  Wassermann  reaction  had  not  been  discovered  at  the 
time  when  this  case  was  seen,  and  since  no  ii[;-ray  examination  of  the 
aortic  arch  was  made,  we  cannot  decide  whether  or  not  the  diastolic 
murmur  was  due  to  a  syphilitic  aortitis. 

The  fever  present  during  the  first  forty-eight  hours  of  his  illness  is 
probably  of  the  cerebral  type,  the  type  often  seen  in  cerebral  hemor- 
rhage, cerebral  tumor,  concussion  or  fracture  of  the  skull,  even  when 
all  infection  can  be  excluded.  This  point  is  sometimes  of  importance 
in  differential  diagnosis,  as  many  physicians  are  prone  to  believe  that 
the  presence  of  such  a  fever  proves  infection. 

Outcome.— Under  hot-air  baths  and  purgatives  he  rapidly  im- 
proved; by  the  19th  he  felt  very  well  and  was  able  to  go  home,  but 
died  there  on  the  23d  of  December. 


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144  DIFFERENTIAL   DIAGNOSIS 


Case  45 


A  wood-chopper  of  sixty- two  entered  the  hospital  February  3,  1904. 
The  patient's  niother  and  one  sister  died  of  consumption;  his  father,  of 
some  unknown  cause;  two  other  sisters,  of  typhoid.  The  patient  him- 
self has  been  in  perfect  health  until  ten  months  ago  and  his  habits  have 
been  excellent.  At  that  time  he  first  noticed  dizzy  spells,  slight  head- 
ache, and  dimness  of  vision.  The  attacks  lasted  ten  to  fifteen  minutes 
and  gradually  increased  in  frequency,  until  during  the  last  month 
the  three  symptoms  above  mentioned  have  been  constant  and  walk- 
ing has  become  very  difficult.  He  has  noticed  numbness  in  his  right 
arm  and  leg,  also  a  very  sHght  numbness  in  his  left  arm.  His  appetite 
and  digestion  are  excellent,  bowels  regular. 

Examination  of  the  internal  viscera  is  negative.  The  arteries 
are  somewhat  thickened  and  tortuous,  with  a  lateral  excursion  in  the 
brachials.  The  right  knee-jerk  is  more  marked  than  the  left.  Plan- 
tars  normal.  Sensation  to  touch  and  temperature  is  absent  in  the 
right  thigh  and  leg.  Pain  sense  and  muscle  sense  present.  Cremas- 
teric reflex  absent  on  the  right.  Fibrillary  twitching  in  the  extensor 
of  the  right  thigh.  Skin  reflex  on  the  right  side  of  the  abdomen 
much  diminished.  The  right  hand  is  weaker  than  the  left.  No  dis- 
turbance of  sensation  in  the  arms.  Blood  and  urine  normal.  Speech 
slow,  but  not  aphasic.  Double  optic  neuritis  is  found  on  examina- 
tion of  the  fundus  oculi. 

Dr.  G.  L.  Walton  thought  there  was  a  new-growth  in  or  near  the 
Rolandic  region  on  the  left,  and  advised  operation  for  decompression. 
During  the  patient's  six  weeks'  stay  in  the  medical  wards  there  was 
no  abnormal  temperature  or  pulse  recorded.  The  patient  had  a  good 
deal  of  headache  up  to  the  12th  of  February,  after  which  it  was  less. 
On  the  17th  it  again  increased  and  his  mental  condition  became  duller. 
He  also  had  some  difficulty  in  swallowing,  which  lasted,  however,  only 
a  few  days. 

On  the  12th  of  March  it  was  noted  that  his  headache  has  not  in- 
creased, but  the  dizziness  was  more  troublesome  and  he  began  to 
become  stuporous,  so  that  he  snored  continuously,  day  and  night.  As 
the  degree  of  optic  neuritis  steadily  increased,  he  was  transferred  to 
the  surgical  wards.  Examination  there  showed  incomplete  fixation 
of  the  eyes  when  they  were  turned  toward  the  left,  the  effort  being  ac- 
companied by  twitching  muscles  of  the  eyeballs  (nystagmus).  When 
the  effort  was  made  to  turn  the  eyes  to  the  right,  the  right  eyeball 
did  not  go  beyond  the  median  line.    The  pupils  were  normal.    The 


VERTIGO  145 

masseter  muscles  were  contracted  on  each  side.  The  right  side  of  the 
face  below  the  eye  moved  less  well  than  the  left.  There  was  diminu- 
tion of  sensation  over  the  whole  right  side  of  the  face,  both  to  touch 
and  temperature.  There  was  considerable  deafness  in  the  right  ear. 
There  was  no  Babinski.  Both  knee-jerks  were  lively.  The  muscles  of 
the  right  leg  were  weaker  and  less  complete  than  those  of  the  left. 
Sensation  of  position  for  the  toes  of  the  right  foot  diminished.  A 
half-dollar  piece  was  not  recognized  by  the  right  hand  and  was  called 
a  jack-knife,  but  it  was  at  once  recognized  by  the  left  hand.  There 
was  some  inco-ordination  of  the  hands,  especially  of  the  right. 

Discussion. — The  history  shows  vertigo  associated  with  numb- 
ness in  the  right  half  of  the  body.  Physical  examination  shows 
weakness;  in  addition,  ataxia  of  the  right  side,  associated  with  optic 
neuritis,  and  later  with  mental  changes  and  dysphagia.  All  this 
points  directly  to  some  focal  brain  lesion,  probably  brain  tumor. 

Arteriosclerosis  is  to  be  excluded.  It  does  not  ordinarily,  if 
ever,  produce  a  double  optic  neuritis,  and  the  gradual  onset  of  mental 
cloudiness  is  not  characteristic.  The  t3^e  of  hemiplegia  associated 
with  arteriosclerosis  is  apt  to  appear  more  suddenly  and  to  involve 
more  extensive  loss  of  power. 

Dementia  paralytica  might  begin  in  this  way  and  might  produce 
many  of  the  symptoms  present  in  this  case.  It  would  be  unusual, 
however,  to  have  no  more  definite  mental  symptoms,  and  double 
optic  neuritis  is  not  the  usual  lesion  found  in  these  cases.  Spinal 
puncture  and  the  examination  of  the  spinal  fluid  for  evidence  of 
syphilis  would  be  the  most  important  point  in  making  more  certain 
our  right  to  exclude  dementia  paralytica,  but  spinal  puncture  is 
sometimes  an  operation  of  serious  danger  in  cases  of  brain  tumor, 
and  when  that  lesion  is  suspected  should  be  performed  with  extreme 
caution  and  only  for  the  best  of  reasons.  The  appearance  of  nystag- 
mus and  astereognosis  goes  to  confirm  a  diagnosis  of  locaHzed  cerebral 
lesion  and,  therefore,  of  a  tumor. 

The  point  of  special  interest  is  the  fact  that  vertigo  was  his  first 
symptom. 

Outcome. — On  the  26th  the  patient  was  trephined  over  the 
Rolandic  area  on  the  left,  the  dura  was  opened,  and  the  brain  exposed. 
■Nothing  abnormal  was  seen.  The  operation  made  no  difference  at 
all  in  the  patient's  symptoms  except  that  on  the  3d  of  April  he  was 
aphasic.  On  the  i6th  of  April  the  brain  was  further  explored  for 
tumor,  but  nothing  found.  There  was  no  considerable  change  in  the 
patient's  condition  until  the  5th  of  May,  when  he  began  to  have 

Vol.  11—10 


146  DIFFERENTIAL  DLAGNOSIS 

convulsive  movements  on  the  left  side.  There  was  considerable 
hernia  of  the  brain  substance.  On  the  24th  of  May  he  died.  Autopsy- 
No.  1220  showed  an  endothelioma  of  the  dura  mater  in  the  posterior 
fossa;  purulent  meningitis;  multiple  gas-cysts  of  the  brain;  broncho- 
pneumonia of  the  left  lung;  lyinphoma  of  the  mediastinal  region; 
cysts  of  the  kidney.  Obsolete  tuberculosis  of  the  upper  lobe  of  the 
left  lung  and  of  the  bronchial  lymphatic  glands.  Slight  arterio- 
sclerosis of  the  aorta. 

Case  46 

A  gynmastic  instructor  of  twenty-eight  entered  the  hospital 
September  21,  1904.  For  the  past  two  weeks  the  patient  has  been 
feehng  weak  and  has  been  troubled  with  dizziness  and  headaches. 
He  has  slept  but  little  and  has  no  appetite.  He  has  never  been  sick 
before  and  has  an  excellent  family  history  and  habits. 

Physical  examination  was  negative.  There  was  a  continued  fever 
and  a  positive  Widal  reaction.  The  white  cells  at  entrance  numbered 
11,200;  hemoglobin,  80  per  cent.  The  urine  was  30  ounces  in  twenty- 
four  hours;  specific  gravity,  1020;  albumin,  very  slight  trace,  and  a 
few  hyaline,  fine  granular  and  coarse  granular  casts.  The  patient 
ran  the  ordinary  course  of  a  typhoid  with  relapse,  and  left  the  hospital 
in  good  condition  on  the  5  th  of  November.  At  the  time  that  he  left 
he  had  slight  cystitis  and  typhoid  bacilli  were  recovered  from  his 
urine.  His  white  count  remained  above  gooo  during  the  whole  of  his 
fever. 

Discussion. — The  case  is  a  typical  illustration  of  vertigo  asso- 
ciated with  an  acute  infectious  disease.  Presumably  the  dizziness 
has  the  same  significance  here  that  headache  does.  Precisely  what 
the  significance  is  we  do  not  know.  It  may  be  toxic,  but  it  may  alsa 
be  circulatory.  The  occurrence  of  nosebleed  at  the  same  period  at 
which  headache  occurs  in  the  beginning  of  infectious  diseases  inclines 
us  to  believe  that  vasomotor  changes  rather  than  purely  toxic  in- 
fluences are  at  work.  In  typhoid  fever  this  is  all  the  more  probable 
because  the  headache  and  vertigo  are  apt  to  decrease  in  the  second 
and  third  week  of  the  disease,  when  the  general  manifestations  of 
what  we  call  toxemia  are  at  their  height. 

There  can  be  no  doubt  that  this  illness  was  typhoid  fever,  but 
it  should  be  specially  noted,  as  a  point  of  great  rarity,  that  the  white 
cells  were  slightly  elevated  during  the  whole  of  his  fever.  This 
probably  does  not  occur  more  than  once  in  a  thousand  cases,  if  so 
often.     But  for  the  finding  of  typhoid  bacilli  in  the  urine  one  might 


VERTIGO  147 

be  almost  disposed  to  doubt  the  diagnosis  of  typhoid  because  of  the 
elevated  leukocyte  count. 

Case  47 

A  hack  driver  of  forty-three,  born  in  Russia,  entered  the  hospital 
January  9,  1905.  For  the  past  eight  months  the  patient  has  had  a 
full  feeling  in  his  head.  On  attempting  any  exertion  he  becomes 
dizzy  and  feels  as  if  he  would  fall.  During  the  same  period  he  has  had 
buzzing  and  roaring  in  his  left  ear  or  sometimes  a  noise  Uke  a  bell, 
and  did  not  hear  well.  In  other  respects  he  feels  perfectly  well,  but 
he  has  fallen  twice  in  six  months  owing  to  vertigo.  He  always  falls 
to  the  right. 

Physical  examination  is  negative  save  as  relates  to  the  ears,  which 
show  evidence  of  labyrinthine  disease.     Romberg's  sign  absent. 

Discussion. — This  case  illustrates  a  typical  Meniere's  complex 
(not  Meniere's  disease),  which  in  this  case  depends  upon  definite 
disease  of  the  labyrinth.  The  diagnosis  depends  upon  a  lack  of  evi- 
dence for  any  other  cause  of  vertigo  and  the  presence  of  a  labyrin- 
thine disease,  as  determined  by  an  expert. 

Outcome. — The  patient  was  transferred  to  the  Eye  and  Ear  In- 
firmary, where  diagnosis  of  labyrinthine  disease  was  confirmed. 

Case  48 

A  sailor  and  marketman  of  thirty-two  entered  the  hospital  March 
II,  1905.  The  patient  has  been  in  the  habit  of  taking  three  whiskies 
a  day,  occasionally  one  before  breakfast.  He  had  gonorrhea  ten  years 
ago,  soft  chancres  eight  years  ago,  and  erysipelas  of  the  face  five  years 
ago.  In  the  past  six  months  he  has  been  troubled  by  dizzy  spells, 
occurring  at  least  once  a  day  and  lasting  a  few  minutes,  especially 
when  he  rises  suddenly  from  a  chair  or  goes  from  a  hot  room  into 
the  open  air.  He  is  obliged  to  sit  down  when  the  attacks  come, 
otherwise  he  would  fall.  During  the  attacks  he  is  conscious,  but  his 
limbs,  he  says,  are  in  clonic  spasm.  There  is  no  involuntary  mic- 
turition and  in  a  couple  of  minutes  he  is  perfectly  well  and  laughing 
at  himself. 

For  six  months  he  has  noticed  dyspnea,  palpitation,  and  edema 
of  the  legs  after  exertion,  and  for  three  months  there  has  been  dis- 
coloration of  the  lower  part  of  the  legs.  All  winter  he  has  found  it 
very  difficult  to  get  warm  and  he  never  sweats  except  in  a  Turkish 
bath.  During  the  last  six  months  his  color  has  been  changing,  so 
that  his  friends  have  nicknamed  Him  "the  Jap."     For  two  weeks  he 


148 


DIFFERENTIAL   DIAGNOSIS 


has  been  unable  to  work  on  account  of  weakness,  yet  he  seems  to  feel 
better  when  exercising.  His  appetite  is  good,  his  bowels  regular,  his 
sleep  restless.     He  often  passes  urine  involuntarily  at  night. 

Physical  examination  shows  marked  pallor  of  the  skin  and  mucous 
membranes.  There  is  a  systolic  murmur  audible  all  over  the  pre- 
cordia,  not  associated  with  other  abnormalities  of  the  heart.  There 
is  soft  edema  of  the  lower  legs  and  marked  varicose  veins  on  both  of 
them.  Otherwise  physical  examination  is  negative.  The  blood 
shows  red  cells,  2,428,000;  white  cells,  3400;  hemoglobin,  50  per  cent. 
Stained  specimen  shows  well-marked  achromia,  but  no  other  changes 


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Fig.  59. — Chart  of  Case  48. 

in  the  red  cells.  Differential  count  normal.  The  urine  averages 
60  ounces  in  twenty-four  hours;  specific  gravity,  1009  to  1012;  no 
albumin;  a  rare  hyaHne  cast  in  the  sediment.  On  the  15th  of  March  it 
is  noticed  that  his  spleen  is  palpable  and  he  has  been  having  a  good 
deal  of  nosebleed.  Examination  of  the  ears  shows  no  explanation  of 
the  dizziness.     The  temperature  is  seen  in  the  accompanying  chart 

(Fig.  59)- 

The  bowels  were  very  loose  during  the  first  and  last  week  of  his 
stay,  at  other  times  they  were  normal.  A  iew  darkened  spots  were 
found  on  the  mucous  membrane  of  the  mouth  and  about  the  scrotum. 
On  the  26th  of  March  he  seemed  to  be  a  little  browner,  but  felt  better 
and  stronger.     There  was  no  reaction  to  tuberculin.     The  blood- 


VERTIGO  149 

count  had  risen  to  2,872,000.  The  red  cells  showed  marked  achromia 
and  deformities  in  shape,  otherwise  the  blood  was  as  before.  The 
stools  were  negative.  There  was  no  incontinence  of  urine  after 
entering  the  hospital,  and  that  previously  mentioned  was  probably 
due  to  drinking  heavily.  On  the  2d  of  April  the  patient  was  again 
given  tuberculin,  and  fourteen  hours  later  showed  a  rapid  rise  in  tem- 
perature to  104°  F.,  followed  by  rapid  lysis.  On  the  12th  of  April 
the  patient  seemed  to  be  stronger  and  had  gained  10  pounds  in  four 
weeks,  but  his  blood-count  showed,  April  15th,  red  cells,  1,976,000; 
otherwise  it  was  as  before.  He  left  the  hospital  on  the  2 2d  of 
April. 

Summary  of  subsequent  out-patient  records:  April  27,  1905,  Well 
except  for  lame  back.     ]^.  Straps. 

May  4th.  Feels  "elegant" — active,  Hvely,  3  to  4  mile  walk  today. 
Before  entrance  much  dyspnea,  now  none.  Vertigo  only  when  he 
first  gets  up.  Much  improved  in  this  respect.  Appetite,  bowels, 
and  sleep  O.  K.  Not  at  work  yet.  Color  still  poor.  Weight,  184 
pounds.  Hemoglobin,  55  per  cent.  Reds,  3,456,000;  whites,  6800. 
Achromia,  small-sized  red  cells,  slight  deformities,  and  increased 
blood-plates.     No  blasts  or  stippling.     Normal  differential  count. 

Discussion. — I  have  introduced  this  case  because  it  seems  to 
me  one  of  great  interest,  although  the  diagnosis  is  by  no  means  clear. 
The  essential  features  of  the  case  are  as  follows:  Marked  secondary 
anemia  associated  with  enlargement  of  the  spleen,  evidence  of  cardiac 
weakness,  vertigo,  a  brownish  color  to  the  uncovered  parts  of  the  skin, 
and  a  negative  tuberculin  reaction,  all  these  sjmiptoms  in  an  alcohohc 
patient  who  very  possibly  has  had  syphiUs. 

Addison's  disease  must,  of  course,  be  considered,  and  it  is  impos- 
sible to  say  that  Addison's  disease  never  gets  well  and  to  deny  the 
possible  correctness  of  that  diagnosis  in  this  case  because  the  patient 
apparently  recovered  or,  at  any  rate,  greatly  improved.  It  is  greatly 
to  be  regretted  that  we  have  no  measurements  of  blood-pressure. 
Were  a  strikingly  low  pressure  recorded — 75  mm.  Hg.  or  lower  for 
the  systoHc  pressure — evidence  of  Addison's  disease  would  be  strength- 
ened. The  presence  of  pigmentation  within  the  mouth  is  of  special 
importance  as  further  strengthening  this  diagnosis.  On  the  other 
hand,  the  negative  tuberculin  reaction,  and  especially  the  fact  that  two 
subcutaneous  injections  of  a  large  dose  of  tuberculin  were  borne  so 
well  by  the  patient,  mihtates  against  the  diagnosis  of  Addison's 
disease.  Such  injections  are  very  dangerous,  and  in  at  least  two 
instances  known  to  me  have  been  followed  immediately  by  death. 


150  DIFFERENTIAL  DIAGNOSIS 

They  should  never  be  given  in  any  case  of  suspected  Addison's  dis- 
ease. 

Syphilis  must  certainly  be  considered  and  might  account  for  all 
the  symptoms  in  the  case.  It  has  been  often  noticed  that  vertigo  is 
a  frequent  and  early  symptom  in  cases  of  syphilis  affecting  the  brain, 
and  there  is  a  great  deal  in  this  case  to  suggest  organic  brain  disease, 
especially  the  clonic  spasms  of  the  limbs,  the  involuntary  micturi- 
tion at  night,  and  the  causeless  anemia  which,  in  a  man  of  his  age 
and  especially  in  a  sailor,  is  more  often  due  to  syphilis  than  to  any 
other  disease.  It  is  greatly  to  be  regretted  that  no  Wassermann 
reaction  was  done.  As  far  as  I  know  he  received  no  antisyphilitic 
treatment,  but  the  fact  that  he  nevertheless  improved  does  not  in- 
validate the  diagnosis  of  possible  syphilis.  A  good  many  similar 
cases  are  on  record. 

Since  the  anemia  was  associated  in  this  case  with  splenic  enlarge- 
ment, we  are  forced  to  consider  the  complex  called  splenic  anemia 
as  a  possible  explanation  of  his  symptoms,  but  this  would  necessi- 
tate neglecting  altogether  the  cerebral  aspects  of  the  case,  and 
would  make  it  improbable  that  so  prompt  an  improvement  should 
occur. 

Outcome. — November  10,  1905.  Feels  first  rate.  Notices  some 
loss  of  strength  in  legs.  Appetite  good.  Bowels  move  daily.  Comes 
to  hospital  for  eczema  on  legs. 

Case  49 

An  Irish  laborer  of  sixty  entered  the  hospital  July  12,  1905.  Three 
days  ago  the  patient  was  exposed  to  very  hot  weather,  and  his  head 
became  so  dizzy  that  he  did  not  know  what  he  was  doing  part  of  the 
time,  yet  he  did  not  give  up  work,  and  next  day  felt  well.  At  noon 
today,  after  working  in  the  sun  all  the  morning,  he  again  began  to  be 
dizzy,  and  finally  could  not  see  and  lost  consciousness.  He  was 
brought  to  the  hospital  in  coma,  with  stertorous  breathing. 

On  physical  examination  the  left  pupil  was  larger  than  the  right; 
both  reacted  normally.  Coma  was  complete.  The  internal  viscera 
showed  nothing  abnormal.  The  temperature  was  104.4°  F.;  pulse, 
112;  respiration,  40.  The  plantar  reflexes  were  normal,  the  others 
not  obtained.  The  urine  showed  a  very  slight  trace  of  albumin,  but 
was  otherwise  negative,  as  was  the  blood. 

Discussion. — Although  we  do  not  understand  the  pathogenesis 
of  sunstroke,  we  have  reason  to  beheve  that  the  temperature  is  ex- 
cessively elevated,  not  only  in  the  places  at  which  we  can  measure  it, 


VERTIGO 


151 


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but  within  the  semicircular  canals  and  everywhere  else.  It  has  been 
well  established  experimentally  that  caloric  stimulation  of  the  in- 
ternal ear,  such  as  might  be  pro- 
duced by  hot  syringing  of  the  ex- 
ternal ear  or  otherwise,  is  prone 
to  produce  vertigo. 

Most  cases  of  sunstroke,  if  we 
are  so  fortunate  as  to  obtain  a 
good  history,  are  preceded  by  ver- 
tigo which  may  last  for  minutes 
or  for  hours,  and  should  warn  the 
patient  that  he  is  in  danger. 
Such  premonitory  symptoms,  Hke 
sunstroke  itself,  are  much  more 
frequent  in  alcoholic  patients.  One 
rarely  sees  a  case  of  sunstroke 
not  previously  weakened  by  alco- 
holic or  some  other  deleterious  in- 
fluence. 

Outcome. — After  a  cold  bath 
he  became  conscious  and  the  tem- 
perature dropped,  as  shown  in  the  accompanying  chart  (Fig.  60). 
He  rapidly  convalesced  and  left  the  hospital  on  the  second  day. 

Case  50 

An  Irish  laborer  of  forty  entered  the  hospital  June  5,  1907.  His 
family  history  and  past  history  are  negative.  The  patient  has  been 
a  hard  drinker  for  many  years.  For  the  past  two  years  he  has  taken 
nearly  a  quart  of  whisky  a  day.  He  had  a  touch  of  the  "horrors" 
five  years  ago.  For  two  years  his  eyesight  has  been  faiHng,  and  nine 
months  ago  he  had  to  stop  work  on  this  account.  Since  then  "he  has 
had  dry  heaves  in  the  morning"  and  has  lost  strength. 

For  seven  months  he  has  had  frequent  dizzy  spells,  which  are  now 
his  main  complaint.  For  five  months  his  hands  and  feet  have  been 
swollen,  and  occasionally  his  face  has  been  puffy.  For  a  month  he  has 
eaten  irregularly  and  little,  has  drank  heavily,  and  been  very  fidgety. 

Physical  examination  shows  good  nutrition,  extreme  motor 
restlessness,  marked  tremor  of  the  hands  and  lips.  Pupils,  glands, 
and  reflexes  are  normal.  Chest  negative.  The  abdomen  is  dis- 
tended and  shows  shifting  dulness  in  the  flanks,  but  no  other  ab- 
normality.    There  is   sKght  edema  of   the  feet.     Urine,  25  ounces 


152  DIFFERENTIAL  DIAGNOSIS 

in  twenty-four  hours;  specific  gravity,  1016;  very  slight  trace  of  al- 
bumin, and  a  very  rare  hyaline  cast.  Systolic  blood-pressure  128  mm. 
Hg.  Blood  negative.  Examination  of  the  fundi  shows  optic  atrophy 
in  the  temporal  half  of  each  disk. 

Discussion. — On  the  hospital  record  the  diagnosis  of  this  case 
stands  as  "alcohoKsm,"  and  it  may  well  be  that  no  other  diagnosis  is 
possible  with  the  known  facts,  but  we  have  every  reason  to  believe 
that  he  has  some  severe  circulatory  disturbances  in  the  portal  sys- 
tem, presumably  cirrhosis,  and  the  bitemporal  atrophy  of  the  optic 
disks  makes  us  very  suspicious  of  some  organic  cerebral  lesion,  pos- 
sibly arteriosclerosis  or  gumma.  Internal  pachymeningitis  is  also  a 
possibility,  but  we  have  no  way  of  coming  to  any  closer  certainty  in 
the  matter.  As  regards  the  supposed  connection  between  alcohol- 
ism and  vertigo,  it  is  notable  that  although  this  patient  has  been  a 
hard  drinker  for  many  years  and  has  taken  a  quart  of  whisky  a  day 
for  two  years,  he  had  no  vertigo  until  the  past  seven  months.  These 
facts  strongly  suggest  that  some  organic  lesion,  something  other  than 
the  purely  toxic  effects  of  alcohol,  has  been  at  work  since  he  began  to 
be  dizzy. 

Outcome. — Within  a  few  days  he  had  lost  his  nervousness  and 
tremor;  he  liked  the  hospital  as  a  hotel,  but  did  not  seem  to  need  it 
in  other  respects.     He  was  allowed  to  go  home  on  the  13  th. 

Case  51 

An  Italian  shoemaker  of  forty-one  enters  the  hospital  January 
29,  1908.  About  two  years  ago  the  patient  began  to  be  dizzy,  at  times 
drowsy,  and  at  other  times  to  have  cramp-like  muscular  pains.  He 
was  in  the  Boston  City  Hospital  for  three  months  without  great  im- 
provement. Nevertheless,  he  has  been  able  to  do  less  and  less  work 
since  that  time,  and  for  the  last  nine  months  has  done  none  at  all. 
Nocturia,  i  to  2,  has  been  present  for  years,  but  in  the  last  seven 
months  has  increased  to  4  or  5.  He  has  no  headache,  no  vomiting, 
dyspnea,  or  edema,  but  for  six  months  his  eyesight  has  been  failing. 
His  family  history  and  past  history  are  entirely  negative. 

The  man  is  poorly  nourished  and  has  a  funnel  breast.  Cardiac 
apex  extends  f  inch  outside  the  nipple,  in  the  fifth  interspace.  There 
is  no  increase  of  dulness  to  the  right.  At  the  base  there  is  a  faint  sys- 
toHc  murmur.  There  are  no  other  abnormalities.  The  artery  walls 
seem  to  be  thickened.  Systolic  blood-pressure  is  205.  Lungs  and 
abdomen  are  negative.  Blood  is  normal.  The  urine  is  35  ounces  in 
twenty-four  hours;  specific  gravity,  1013;  a  trace  of  albumin;  a  few 


VERTIGO  153 

hyaline  and  granular  casts.  Retinal  examination  shows  hemor- 
rhages on  each  side.  During  his  four  days'  stay  in  the  ward  he  felt 
perfectly  able  to  work  and  had  no  symptoms  except  failing  vision. 

Discussion. — Although  we  do  not  understand  precisely  what  is 
the  relation  between  vertigo  and  high  blood-pressure,  we  cannot  doubt 
that  there  is  some  such  relation.  Not  every  case  of  hypertension 
suffers  from  vertigo,  but  a  considerable  percentage  of  such  cases  do 
suffer  in  this  way,  and  that  percentage  is  about  the  same  whether  the 
cause  of  the  vertigo  and  hypertension  resides  wholly  in  the  kidney  or 
not. 

In  the  present  case  everything  points  to  the  presence  of  a  chronic 
glomerular  nephritis.  The  age,  the  long-standing  nocturia,  the  enlarged 
heart  and  high  blood-pressure,  the  condition  of  the  urine,  and  retinal 
hemorrhages — 9,11  point  in  the  same  direction. 

Case  52 

An  Irish  laborer  of  twenty-seven  entered  the  hospital  July  9,  1909. 
The  patient  has  a  good  family  history  and  past  history,  though  he  has 
been  treated  in  the  Out-patient  Department  for  two  months  for 
psoriasis. 

Five  weeks  ago  he  began  to  have  constant  vertigo,  day  and  night, 
so  severe  that  he  was  unable  to  walk  without  staggering.  This 
vertigo  was  accompanied  by  headache,  especially  on  the  right  side 
of  the  head  and  in  the  right  eye.  It  came  usually  at  8  p.  m.,  lasted  a 
week,  did  not  disturb  sleep.  After  that  it  shifted  to  the  left  side  of 
the  head  and  the  left  eye  for  a  week.  For  the  past  fortnight  he  has 
had  no  headache  and  his  vertigo  has  been  much  less  severe,  so  that  he 
can  walk  without  difficulty.  He  has  never  fallen  and  has  no  spasms 
or  convulsions,  though  occasionally  his  left  hand  trembles  a  Httle. 
For  the  past  month  his  eyesight  has  been  poorer  than  usual,  but  lately 
is  improving  again.  The  cessation  of  his  headaches  was  coincident 
with  the  beginning  of  hydrotherapeutic  procedures  two  weeks  ago. 
He  has  no  deafness  and  no  other  symptoms  except  those  above  men- 
tioned.    His  appetite  and  digestion  are  good  and  his  bowels  regular. 

Save  for  the  areas  of  psoriasis,  physical  examination  is  negative. 
Temperature,  blood,  and  urine  were  normal  throughout.  The 
fundus  oculi  also  normal.  Under  encouragement,  hydrotherapy, 
and  static  electricity  he  did  very  well,  but  on  the  21st  of  July  the 
Wassermann  reaction  was  found  to  be  positive.  Nevertheless,  he  was 
discharged  the  same  day. 

Discussion. — This  case  was  diagnosed  as  one  of  "hysteria"   at 


154  DIFFERENTIAL  DIAGNOSIS 

the  hospital,  but  in  view  of  the  positive  Wassermann  reaction  this 
diagnosis  seems  to  me  improbable.  Of  course,  it  is  perfectly  possible 
for  hysteria  to  exist  in  an  Irish  laborer  of  twenty-seven,  but  such  a 
coincidence  is  certainly  infrequent,  and  as  we  know  that  vertigo  is  a 
frequent  accompaniment  of  various  stages  of  syphilitic  infection,  it 
seems  much  more  reasonable  to  explain  this  patient's  dizziness  as 
due  to  some  cerebral  change  dependent  upon  the  activities  of  the 
Spirocha^ta  pallida.  The  chief  reasons  for  the  diagnosis  of  hysteria 
seem  to  be  the  improvement  of  the  patient  following  encourage- 
ment, hydrotherapy,  and  static  electricity,  but  this  improvement 
may  well  have  been  a  coincidence.  I  am  inclined  to  think  that  such 
w^as  the  case. 

Outcome. — August  20th  he  was  walking  better  and  improving 
generally.     Soon  after  he  returned  to  Ireland  and  was  lost  sight  of. 

Case  53 

An  Armenian  laborer  of  seventy-one  entered  the  hospital  Sep- 
tember 29,  1909.  Six  months  ago  the  patient  began  to  have  pain  in 
his  neck  and  the  back  of  his  head,  gradually  extending  to  the  fore- 
head, though  it  was  still  in  the  back  of  the  neck.  The  pain  is  con- 
tinuous and  accompanied  by  occasional  dizzy  spells,  with  ringing  in 
the  left  ear.  Turning  his  head  causes  pain  in  the  right  side  of  his 
neck.  He  has  no  other  symptoms,  and  has  never  been  sick  before 
except  for  an  attack  of  rheumatism,  two  years  ago,  which  confined 
him  to  bed  two  months. 

Visceral  examination  was  negative  except  that  deep  pressure  in 
the  right  flank  during  inspiration  was  sHghtly  painful.  The  knee- 
jerks  were  increased.  There  was  no  stiffness  of  the  neck,  no  dis- 
turbances of  sensation.  The  right  pupil  was  circular  and  reacted 
normally.  The  left  eye  was  glass.  The  fundus  oculi  showed  optic 
neuritis,  the  disk  border  completely  obHterated,  and  moderate  prom- 
inence of  the  disk  surface.  There  was  a  very  little  exudate,  but 
numerous  hemorrhages  extending  from  the  upper  inner  quarter  out 
into  the  adjacent  retina.  The  headache  persisted  (though  there 
was  no  vomiting)  until  the  6th  of  October,  when,  without  preceding 
nausea,  he  suddenly  emptied  his  stomach.  Lumbar  puncture  showed 
clear  fluid  under  no  excessive  pressure  and  with  no  increase  of  cel- 
lular content.  Wassermann  reaction  was  negative.  Under  two 
weeks  of  antisyphilitic  treatment  the  patient  did  not  improve  at  all. 

Discussion. — Brain  tumor  is  unusual  at  the  age  of  seventy-one. 
We  should  make  every  effort  in  a  case  presenting  cerebral  symptoms 


VERTIGO  155 

at  this  age  to  explain  them  as  results  of  arteriosclerosis  or  syphilis; 
but  in  this  patient  the  negative  results  of  the  Wassermann  test,  the 
lumbar  puncture,  and  the  antisyphilitic  treatment  make  it  improb- 
able that  he  is  suffering  from  syphilis. 

In  favor  of  brain  tumor  are  headache,  vertigo,  cerebral  vomiting, 
and  the  double  optic  neuritis. 

Outcome. — October  15th  the  skull  was  first  opened  in  the  right 
temporoparietal  region.  When  the  outer  table  was  penetrated  and 
before  the  skull  was  opened  the  patient  stopped  breathing.  His 
pulse  was  of  good  quality,  and  artificial  respiration  was  done  for 
about  half  an  hour  without  improvement  in  the  power  of  spontaneous 
respiration.  The  wound  was  then  closed  and  artificial  respiration 
continued  steadily  for  six  hours,  during  which  period  his  color  remained 
good,  but  his  pulse  gradually  weakened  until  his  heart  stopped. 
Autopsy  No.  2464  showed  cyst  of  the  cerebellum  with  old  hemorrhage 
into  it,  internal  hydrocephalus,  arteriosclerosis  of  the  coronary  arte- 
ries, and  hemorrhagic  edema  of  the  lungs. 

Case  54 

A  bartender  of  thirty-four  entered  the  hospital  January  22,  19 10. 
Family  history  was  negative.  Ten  years  ago  he  had  what  was  called 
^'syphihs"  and  was  under  treatment  two  or  three  years.  Three  years 
ago  he  had  severe  headache  for  two  or  three  weeks.  After  glasses 
were  fitted  the  headache  ceased  and  has  rarely  troubled  him  since 
until  last  fall,  when  he  began  to  have  pain  at  the  nape  of  the  neck, 
always  worse  at  night,  and  usually  confined  to  the  nape,  but  occa- 
sionally affecting  the  left  side  or  the  forehead. 

December  10,  1909,  the  pain  was  so  severe  that  he  stopped  work. 
For  the  week  succeeding  that  time  he  was  very  dizzy,  vomited  fre- 
quently, and  had  cramps  and  numb  feelings  in  his  right  arm,  leg, 
and  the  right  side  of  his  face.  About  this  time  he  was  almost  blind 
for  three  days,  after  which  his  sight  improved.  The  headache  con- 
tinued, and  five  days  ago  he  had  another  bad  attack  of  vertigo  and 
vomiting  and  lost  power  over  the  right  side  of  his  body.  The  next 
three  days  he  was  blind,  but  all  of  these  symptoms  have  now  cleared  up, 
though  he  still  has  some  headache  and  does  not  see  well.  His  sleep 
has  been  poor  for  six  weeks  and  he  has  had  no  appetite  for  a  week. 

On  physical  examination  the  patient  was  well  nourished,  the  left 
pupil  larger  than  the  right,  both  reacting  normally.  There  was  no 
glandular  enlargement  and  the  tongue  came  out  straight.  Visceral 
examination  was  normal.     There  was  a  slight  loss  of  power  in  the 


156  DIFFERENTIAL  DL\GNOSIS 

right  arm  and  leg,  but  no  paralysis.  The  fundi  were  perfectly  normal. 
Dr.  James  J.  Putnam,  who  saw  him  on  the  24th,  thought  the  hemi- 
plegia might  be  functional.  He  found  some  paresthesia  of  the  right 
hand,  arm,  leg,,  and  the  right  side  of  the  face,  and  shght  ataxia  of  both 
arms,  especially  the  right. 

Discussion. — The  essentials  of  the  history  in  this  case  are  a  syph- 
ilitic infection  ten  years  earher,  a  headache  of  three  years'  duration, 
apparently  reheved  at  first  by  glasses,  but  recently  returning;  then 
one  month  ago,  vertigo,  vomiting,  paresthesia,  and,  later,  hemiplegia 
on  the  right  side,  with  poor  eyesight  for  three  days. 

In  a  patient  of  thirty-four  it  seems  unreasonable  to  explain  these 
sj'Tnptoms  as  a  result  of  arteriosclerosis  unless  we  are  perfectly  cer- 
tain that  we  cannot  refer  them  to  sj^hilis.  With  so  much  in  this 
patient's  history  that  suggests  syphilis,  it  seems  to  me  that  treat- 
ment must  be  based  on  this  beHef . 

We  may  admit  that  cerebral  tumor  or  abscess  might  produce 
the  same  troubles,  but  the  negative  fundus  is  against  both  of  these 
diagnoses.  In  point  of  fact,  what  we  really  recognize  by  the  symptom 
group  presented  in  this  case  is  the  presence  of  increased  intracranial 
pressure  and  of  some  focal  lesion  such  as  can  produce  partial  hemi- 
plegia. Beyond  this,  our  reasoning  to  more  exact  diagnosis  must 
be  based  upon  our  statistical  knowledge  of  a  relative  frequency  of  the 
diseases  capable  of  causing  such  a  group  of  symptoms  in  a  bartender 
of  thirty-four. 

Outcome. — Within  a  few  days  after  this  he  began  to  show  marked 
improvement  mider  antisyphilitic  remedies.  His  headache  was 
much  less  and  he  was  up  and  about  the  ward.  At  no  time  was  there 
any  abnormality  about  his  temperature,  pulse,  respiration,  blood- 
pressure,  blood,  or  urine.  He  gained  5  pounds  during  his  ten  days  in 
the  hospital  and  went  home  on  the  2d  of  February. 

Two  years  later  he  reported,  looking  and  feehng  perfectly  well. 
He  had  had  two  bad  attacks  in  the  past  summer,  with  nausea  and 
blindness,  lasting  two  hours,  and  one  still  worse  attack  in  August, 
191 1,  when  he  was  unconscious  for  thirty-six  hours.  His  vertigo  is 
now  practically  gone,  but  it  is  noticeable  that  as  he  gives  the  fore- 
going account  he  stumbles  now  and  then  in  his  speech.  .  Perhaps 
paresis  is  developing. 

Case  55 

A  mill  operative  of  twenty-six,  born  in  Russia,  entered  the  hospital 
March  14,  1910.  The  patient  was  sent  in  from  the  Out-patient 
Department  (No.  154,217)  for  vertigo  and  staggering  gait.     Cerebral 


VERTIGO 


157 


tumor,  syphilis,  and  ear  disease  had  been  considered  as  diagnoses. 
The  patient's  family  history  and  past  history  were  negative. 

The  patient  has  had  dizzy  spells  for  five  months,  and  says  she 
has  had  headache  night  and  day  for  three  months.  She  now  cannot 
walk  alone.  There  has  been  no  vomiting,  and  her  eyes  and  ears  do 
not  trouble  her. 

Physical  examination  showed  good  nutrition,  slight  pallor,  pupils 
slightly  irregular,  but  reacting  normally.  Visceral  examination  was 
negative,  but  the  patient  could  not  stand  with  the  feet  together  and 
the  eyes  shut,  and  walked  with  a  very  unsteady  gait.  The  plantars 
and  knee-jerks  were  normal.  The  fundus 
oculi  normal.  Ears  negative.  Wasser- 
maim  positive.  Dr.  J.  J.  Putnam  con- 
sidered it  tumor  of  the  cerebellum.  By 
April  12  th  she  was  able  to  walk  with  only 
a  little  assistance.  In  the  meantime 
mercurial  inunctions  had  been  given  daily, 
and  20  gr.  potassium  iodid,  three  times 
a  day.  The  stools  showed  many  eggs 
of  the  Trichiuris  trichiura.  The  blood 
showed  slight  achromia  and  some  varia- 
tions in  size  and  shape,  otherwise  nothing 
abnormal.  Systolic  blood-pressure,  155. 
The  fever  during  first  week  in  the  hospital 
was  as  seen  in  the  accompanying  chart 
(Fig.  61).  After  that  it  was  normal. 
Blood  and  urine  normal.  Studied  in 
the  neurologic  wards,  it  was  found  that  the 
patient  would  stand  if  she  were  scolded, 
but  if  not  scolded  she  would  sway  and  tend 

to  fall  to  the  left.  She  remained  there  three  weeks  and  left  with  the 
diagnosis  of  "debiHty."  At  the  time  of  discharge  nothing  abnormal 
could  be  found. 

Discussion. — On  the  hospital  records  the  diagnosis  of  this  case 
stands  as  "debility."  This  diagnosis  was  made  four  years  ago,  and  I 
cannot  believe  that  anyone  would  consider  it  justified  today.  Ap- 
parently the  idea  that  this  patient  had  no  organic  disease  was  based 
upon  the  fact  that  she  stood  without  swaying  when  they  scolded  her, 
and  could  not  stand  so  unless  they  scolded  her.  But  this  only  gives 
the  proof  that  there  may  be  a  functional  and  psychic  element  in  the 
case  of  a  person  suffering  from  severe  organic  disease. 


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158  DIFFERENTIAL  DIAGNOSIS 

To  me  it  seems  tolerably  obvious  that  when  a  woman  of  twenty- 
sLx  has  a  blood-pressure  of  155,  a  slight  anemia,  a  positive  Wasser- 
mann  reaction,  and  has  suffered  for  five  months  with  headache, 
vertigo,  and  ataxia,  we  should  make  a  diagnosis  of  syphilitic  disease 
affecting  some  part  of  the  brain,  presumably  the  meninges,  possibly 
the  arteries.  Certainly  she  should  be  treated  upon  this  basis,  though 
brain  tumor  cannot  be  excluded.  Apparently  no  careful  tests  of 
labyrinthine  function  were  made. 

I  wish  to  express  here  my  conviction  that  a  great  many  bad  mis- 
takes are  made  in  the  management  of  cases  of  illness  because  we  have 
in  our  minds  a  hard-and-fast  alternative.  The  patient  before  us 
must,  we  say,  have  either  an  organic  disease,  a  functional  disease,  or 
no  disease  at  all.  But  it  seems  to  me  most  important  to  recognize 
that  the  patient  with  indubitable  anatomic  changes  in  one  or  another 
organ  may  also  have,  on  top  of  this,  a  variety  of  symptoms  which  are 
essentially  functional  or  mental  and  can  be  removed  by  change  in 
environment,  in  the  patient's  point  of  view,  or  by  anything  that 
instils  hope.  I  have  in  mind  a  case  of  tabes  dorsalis  following  a 
known  syphilitic  infection;  the  patient  had  Argyll-Robertson  pupils, 
absent  knee-jerks,  Romberg's  sign,  lancinating  pains,  and  some  dis- 
turbances in  the  sphincters,  but,  in  addition  to  these  troubles,  he  was 
obsessed  with  the  idea  that  he  could  never  work  or  walk  again,  that 
he  was  a  useless  encumberer  of  the  earth,  and  forever  disgraced.  When 
these  ideas  were  expelled  from  his  mind  and  a  good  job  was  found  for 
him,  he  lost  his  pains  altogether,  became  able  to  walk  as  well  as  any 
one  else,  gained  20  pounds  in  weight,  and  is  today  a  picture  of  health 
and  happiness,  although  he  has  his  tabes  and  always  will  have  it,  and 
although  his  pupils  and  knee-jerks  are  as  abnormal  as  ever. 

The  lesson  taught  by  this  case  should  always  be  remembered  at 
the  outset  of  our  treatment,  and  especially  of  our  prognosis,  in  cases 
of  incurable  organic  disease.  Recognizing  that  we  cannot  cure  the 
latter,  we  must  remember  that  there  is  no  limit  to  the  amount  of 
functional  and  curable  trouble  which  might  be  superimposed  upon 
and  mixed  up  with  the  underlying  trouble.  Recognizing  frankly  that 
we  cannot  cure  the  disease,  we  may  yet  hope  to  cure  the  patient  of 
most  of  the  troubles  which  torture  him.  It  is  here  that  quacks  and 
irregular  practitioners  of  various  types  score  their  successes  in  patients 
"given  up  by  regular  physicians." 

Outcome. — December  28,  191 2,  a  letter  received  from  a  friend 
states  that  the  patient  returned  to  Russia,  and  has  been  better  during 
the  summer  and  worse  in  the  winter,  since  leaving  this  country. 


VERTIGO  159 


Case  56 


A  brick-mason  of  fifty-six  entered  the  hospital  February  28,  19 10. 
The  patient  was  sent  in  from  the  Out-patient  Department  with  a 
diagnosis  of  "general  paresis"  or  "cerebral  syphilis."  One  paternal 
uncle  died  insane;  otherwise  the  patient's  family  history  is  excellent 
and  he  has  three  healthy  children.  Three  weeks  ago  he  had  an  ab- 
scess in  the  region  of  the  anus;  otherwise  he  has  considered  himself 
entirely  well.  Last  September  his  mother,  with  whom  he  has  lived, 
died,  leaving  him  only  a  quarter  of  her  property.  This  resulted  in 
litigation  which  has  continued  ever  since.  Since  last  October  he  has 
noticed  a  girdle  sensation  about  his  waist  and  he  has  been  short 
of  breath,  but  considered  himself  fairly  well  until  three  weeks  ago, 
when  he  began  to  stagger  in  his  gait  on  account  of  dizziness,  and  this 
symptom  has  rapidly  become  aggravated  since.  At  present  he  gropes 
about  upon  his  feet  as  if  he  were  blind.  Twelve  days  ago  he  began  to 
vomit  profusely,  and  ten  days  ago  he  began  to  talk  in  a  rambhng 
manner,  turning  rapidly  and  irrationally  from  one  subject  to  another. 
In  the  last  two  days  his  friends  say  there  is  no  sense  in  what  he  says,  but 
he  has  had  no  hallucinations  or  illusions.  His  head  feels  full,  but  does 
not  ache.  He  seems  listless  and  sleepy,  but  has  not  been  in  bed, 
though  he  gave  up  work  three  weeks  ago. 

Physical  examination  showed  poor  nutrition,  good  color,  and  slight 
puffiness  under  the  eyes.  The  pupils  were  oval  in  outline,  irregular, 
the  left  greater  than  the  right.  They  reacted  fairly  well  to  light,  but 
better  to  distance.  The  tongue  showed  no  tremor  or  deviation. 
The  heart's  apex  extended  i^  cm.  to  the  left  of  the  nipple.  The 
right  border  4  cm.  from  midsternum.  No  murmurs  or  accentuations. 
Slight  dulness  and  diminished  breath  sounds  were  detected  at  the 
base  of  the  right  lung  behind.  Otherwise  the  lungs  were  normal; 
likewise  the  abdomen.  At  the  top  of  the  right  testis  a  small  nodular 
mass  was  felt,  and  on  the  front  of  the  scrotum  there  were  a  few  soft 
yellow  areas,  surrounded  by  an  infiltrated  reddened  zone.  Knee- 
jerks  were  sluggish  and  there  was  a  suggestion  of  Babinski's  reaction 
on  each  side.  No  clonus.  Double  Kernig  sign.  Gait  very  un- 
steady.    Neck  somewhat  stiff. 

White  cells,  12,500;  hemoglobin,  90  per  cent.  Urine  1018  in  spe- 
cific gravity,  with  the  slightest  possible  trace  of  albumin  and  with  an 
occasional  hyaline  or  fine  granular  cast.  Systolic  blood-pressure,  145. 
Temperature  as  seen  in  the  accompanying  chart  (Fig.  62).  The  fundus 
oculi  was  normal. 


i6o 


DIFFERENTLA.L  DL\GNOSIS 


The  patient's  handwriting  was  very  poor  and  he  often  made 
meaningless  signs.  March  ist  lumbar  puncture  was  done,  and  about 
lo  c.c.  of  clear  colorless  fluid  was  obtained  under  slightly  increased 
pressure.  The  fluid  reduced  Fehling's  solution,  did  not  clot,  was 
negative  on  culture,  and  showed  in  the  sediment  only  a  rare  lympho- 
cyte. The  Wassermann  reaction  was  positive.  On  March  3d  ptosis 
of  the  left  eyelid  appeared.  On  the  4th  the 
left  pupil  became  larger  than  the  right. 

Discussion. — The  gist  of  this  case  seems 
to  be  that  the  patient  has  suffered  from  ver- 
tigo, ataxia,  dyspnea,  and  ■  a  girdle  sensation 
for  five  months;  that  for  twelve  days  he  has 
had  vomiting  and  an  abnormal  mental  state 
characterized  by  listlessness,  stupidity,  and 
rambhng  talk. 

In  the  physical  examination  part  of  the 
findings  suggest  a  tuberculous  process  and  part 
a  syphiUtic.     The  signs  at  the  base  of  the  right 
lung,  the  nodule  in  the  testis,  the  stiff  neck,  the 
fever  and  Kernig's  sign,  are  what  we  should  ex- 
pect with  a  tuberculous  process  involving  the 
brain  and  other  organs.     On  the  other  hand, 
the  condition  of  the  pupils,  the  sluggish  knee- 
jerks,  the  positive  Wassermann  reaction,  the 
speech,  and  handwriting  incline   us   toward  a 
diagnosis  of  syphilis. 
The  ocular  ptosis  might  be  explained  either  by  syphilitic  or  tuber- 
culous meningitis  at  the  base  of  the  brain.     The  condition  of  the 
spinal  fluid  does  not  favor  either  hypothesis. 

On  the  whole,  the  diagnosis  which  I  favored  during  the  patient's 
life  was  syphilis. 

Outcome. — He  was  given  vigorous  antisyphilitic  treatment,  but 
got  steadily  worse  and  died  on  the  7th;  in  the  last  twenty-four  hours 
of  hfe  there  were  signs  of  solidification  at  the  right  base.  Autopsy 
No.  2553  showed  general  mihary  tuberculosis,  tuberculous  meningitis, 
chronic  adhesive  pericarditis. 


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56. 


Case  57 

A  laborer  of  forty-six  entered  the  hospital  May  27,  19 10.  Vertigo 
was  the  patient's  chief  complaint,  and  this  was  first  noticed  five 
weeks  ago,  when  it  attacked  him  while  at  work  and  was  accompanied 


VERTIGO 


l6l 


by  a  shaking  chill.  Since  then  he  has  had  many  such  attacks,  though 
he  has  never  fallen  or  lost  consciousness.  During  the  first  week  of  this 
trouble  he  vomited  much  and  he  has  been  unable  to  work  since  the 
onset  of  his  symptoms.     He  has  had  no  edema,  no  loss  of  weight. 

Physical  examination  showed  a  well-nourished,  ruddy  looking 
Irishman.  Normal  pupils  and  reflexes.  Heart's  apex  extended  i 
inch  outside  the  nipple,  the  right  border  i|  inch  from  midsternum. 
The  sounds  at  the  apex  were 
irregular  in  force  and  frequency; 
second  sound  always  faint, 
sometimes  inaudible.  The  heart 
sounds  came  in  pairs,  the  first 
sound  of  the  second  pair  being 
less  booming  and  more  valvular 
than  the  other.  With  the  sec- 
ond of  the  pair  there  was  a 
venous  pulse  in  the  neck.  Sys- 
tolic blood-pressure,  130  mm. 
Hg.  The  apex  pulse  was  very- 
slow  at  entrance  (Fig.  63). 
Many  beats  were  not  trans- 
mitted to  the  wrist.  Blood  and 
urine  normal.  Lungs  and  ab- 
domen normal.  The  patient's 
physician,  seen  on  the  31st,  said 
that  he  saw  the  patient  April 
1 8th  and  found  his  pulse  then  regular.  Dizzmess  continued  even 
when  the  patient  was  lying  quietly  in  bed. 

Discussion. — Five  weeks'  vertigo  in  a  patient  with  an  enlarged, 
irregular,  weak  heart  and  no  definite  signs  of  arteriosclerosis,  of 
kidney  disease,  or  of  aural  trouble,  may  naturally,  I  think,  be  at- 
tributed to  poor  cerebral  circulation,  local  anemia.  The  only  diffi- 
culty with  this  explanation  is  that  the  patient's  vertigo  continued 
even  when  he  was  lying  flat  in  bed.  Possibly  the  very  slow  pulse 
may  have  had  something  to  do  with  it. 

Precisely  what  the  relation  is  between  heart  disease  and  vertigo 
no  one  seems  to  know.  A  considerable  proportion  of  all  these  cases 
of  failing  heart,  probably  one-tenth,  are  more  or  less  troubled  with 
dizziness,  but  it  is  not  always  those  with  the  poorest  circulation  who 
have  the  most  vertigo,  nor  can  we  associate  the  giddiness  with  any 
single  type  of  heart  trouble.     It  has  not  seemed  to  me  any  commoner 

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^ 

^ 

% 

V 

s 

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^ 

= 

^ 

J 

y 

= 

= 

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Fig.  63. — Chart  of  Case  57. 


1 62  DIFFERENTIAL  DIAGNOSIS 

in  the  elderly  than  in  the  young  subjects  of  heart  disease.  If  this 
impression  is  true,  it  militates  against  the  supposition  that  cerebral 
arteriosclerosis  is  at  the  bottom  of  the  whole  thing. 

Outcome. — As  the  pulse-rate  rose  this  dizziness  did  not  seem  to 
disappear,  but  by  the  middle  of  June  he  felt  a  good  deal  better,  and 
on  the  1 6th  he  was  allowed  to  go  home.  Throughout  his  stay  in  the 
hospital  he  had  a  good  deal  of  headache.  Tracings  were  made  from 
the  neck  veins,  but  were  not  satisfactory.  I  cannot  make  a  diag- 
nosis in  this  case,  but  should  suspect  that  the  vertigo  is  due  in  some 
way  to  poor  cerebral  circulation. 

Case  58 

A  man  of  seventy-three  enters  the  hospital  June  13,  19 10.  The 
patient  has  lost  one  brother  by  tuberculosis;  except  for  this  his  family 
history  is  negative.  Thirty  years  ago  he  had  an  attack  of  inflamma- 
tory rheumatism.  Otherwise  he  has  been  well  until  the  present  year. 
His  habits  are  excellent.  A  year  ago  he  had  to  give  up  work  on  account 
of  dizziness,  which  was  first  noticed  five  years  ago  when  he  started 
quickly  to  walk  or  to  rise  from  a  chair.  These  attacks  have  increased 
in  severity  and  frequency  since  that  time  and  he  has  fallen  uncon- 
scious many  times.  Within  the  past  year  he  thinks  he  must  have 
had  two  hundred  attacks,  varying  from  three  minutes  to  three-quarters 
of  an  hour  in  length.  He  usually  has  about  half  a  minute's  warning, 
then  everything  turns  black,  he  sees  stars,  his  head  whirls,  and  he 
falls  unconscious.  After  the  attack  he  often  has  a  severe  general 
headache,  lasting  about  three-quarters  of  an  hour.  He  can  easily 
bring  on  another  attack  by  exertion,  and  for  a  year  past  any  such 
exertion  produced  considerable  dyspnea.  Previous  to  a  year  ago  he 
could  run  or  make  any  other  severe  exertion  easily.  For  ten  years 
he  has  had  nocturia,  2  to  3.  He  has  always  been  very  emotional,  and 
as  he  told  the  above  story  his  eyes  filled  with  tears  several  times. 

Physical  examination  shows  a  poorly  nourished  old  man,  who  yet 
seems  young  for  his  age.  His  pupils  are  slightly  irregular,  the  right 
larger  than  the  left,  and  both  react  sluggishly.  The  heart's  apex 
is  in  the  nipple  line,  fifth  space;  sounds  regular  and  of  good  quality. 
At  the  apex  a  loud  systolic  musical  murmur  transmitted  all  over 
the  chest.  The  pulmonic  second  sound  slightly  accentuated.  The 
artery  walls  are  thickened,  cord-like,  and  a  few  roughnesses  are  pal- 
pable on  the  right  radial.  The  brachials  are  tortuous  and  pulsate 
laterally.  Systolic  blood-pressure  is  137  mm.  Hg.;  diastolic,  72  mm. 
Hg.     The  second  sound,  both  at  the  apex  and  in  the  second  right 


VERTIGO  163 

interspace,  is  feeble,  but  there  is  no  diastolic  murmur.  The  pulse 
is  of  the  Plateau  type.  The  Wassermann  reaction  is  negative.  A 
radiograph  taken  at  7  feet  shows  an  aortic  shadow,  9  cm.  wide,  oppo- 
site the  manubrium. 

Discussion. — A  good  many  things  in  this  case  suggest  a  simple 
senihty  without  definite  organic  lesion,  but  an  aortic  shadow  9  cm. 
wide  cannot  be  thus  explained.  The  aorta  must  be  either  tortuous  or 
dilated,  and  the  condition  of  the  heart  and  arteries  also  suggest  arterio- 
sclerosis. On  the  whole,  I  do  not  see  anything  in  the  case  which 
cannot  be  explained  by  arteriosclerosis,  though  it  is  a  little  surprising 
that  his  blood-pressure  is  so  low. 

The  condition  of  the  pupils  is  such  as  we  often  find  in  arterio- 
sclerotic old  men.  Whether  the  arteriosclerosis  has  anything  to  do 
with  it  or  not  I  do  not  know.  The  case  might  be  taken  as  typical  of 
a  very  large  number  in  which  vertigo  is  the  presenting  symptom,  and 
arteriosclerosis  is  the  best  diagnosis  that  we  can  make. 

Outcome. — During  a  week's  stay  in  the  hospital  the  patient  was 
entirely  comfortable  and  showed  nothing  abnormal  in  the  ears,  blood, 
and  urine.  He  had  headache  almost  daily,  and  on  the  20th  was 
allowed  to  go  home. 

Case  59 

A  steamfitter  of  thirty-four  entered  the  hospital  June  24,  19 10. 
His  family  history  is  negative  and  he  has  never  been  sick  until  within 
a  year.  In  February,  1910,  he  had  "the  grip"  and  was  in  bed  a  week. 
Since  that  time  he  thinks  he  has  not  been  as  strong  and  has  had  a  shght 
cough,  off  and  on,  but  has  had  no  definite  symptoms  until  twelve  days 
ago. 

Twelve  days  ago,  while  threading  a  pipe,  he  was  suddenly  taken 
with  weakness,  dizziness,  faintness,  together  with  shortness  of  breath. 
He  had  to  give  up  work  and  has  had  more  or  less  similar  trouble  ever 
since,  associated  with  a  rather  sharp  pain  in  the  region  of  the  navel, 
coming  once  or  twice  a  day,  usually  about  four  hours  after  meals  and 
lasting  four  or  five  minutes.  This  pain  usually  causes  vomiting  and  is 
relieved  by  it.  ■  He  has  seen  no  blood  in  the  vomitus  or  in  the  stools. 
He  has  lost  about  25  pounds  in  four  months,  but  worked  until  about 
a  week  ago. 

On  physical  examination  the  patient's  face  was  tanned  and  he 
looked  healthy.  There  was  no  lead  line;  pupils  and  reflexes  normal; 
internal  viscera  normal.  Blood  and  urine  not  remarkable.  SystoHc 
blood-pressure,   90  mm.  Hg.     Temperature,   pulse,   and    respiration 


1 64  DIFFERENTIAL  DIAGNOSIS 

normal  during  five  weeks'  observation.  Guaiac  reaction  negative  in 
ten  examinations,  positive  in  one.  The  patient  vomited  almost  every 
day  until  July  3d,  no  cause  for  the  vomiting  being  apparent.  Blood- 
pressure  continued  between  80  and  90,  more  often  at  the  lower  figure 
during  the  first  three  weeks  of  his  stay.  Later  it  rose  somewhat,  so 
that  by  the  end  of  July  it  ranged  about  100.  The  skin  tuberculin  test 
was  positive.  After  the  3d  of  July  he  ceased  vomiting  and  gradually 
gained  strength.  On  the  i8th  the  stomach-tube  was  passed,  but  no 
fasting  contents  obtained.  After  a  test-meal  the  gastric  contents 
showed  no  hydrochloric  acid  and  a  moderately  strong  reaction  to 
guaiac.  The  capacity  of  the  stomach  could  not  be  ascertained.  The 
-  Wassermann  reaction  was  negative. 

During  his  first  week  in  the  hospital  the  patient  lost  5  pounds,  but 
after  that  time  held  his  weight  steadily,  and  on  the  28th  of  July 
left  the  hospital,  much  relieved. 

He  re-entered  on  the  nth  of  August,  1910,  after  being  at  the 
Waverley  Convalescent  Home  in  the  interim.  At  this  time  he 
remembered  that  in  the  previous  April  and  May  he  had  been  so 
thirsty  that  he  drank  5  gallons  of  water  a  day  when  working.  Never- 
theless he  says  that  up  to  June  loth  he  was  reputed  the  strongest  man 
in  his  shop.  This  time  it  was  noticed  that  the  skin  of  his  axillae  and 
groins  was  pigmented  and  the  mucous  membranes  of  his  Hps  as  well. 
On  the  hard  palate  a  few  line  pigmented  spots  were  also  noticed. 
Otherwise  the  physical  examination  was  essentially  as  before.  He 
could  eat  nothing  but  crackers  and  milk,  and  vomited  that  occa- 
sionally. On  the  12th  he  had  a  severe  attack  of  abdominal  cramps, 
doubhng  him  up,  and  relieved  only  by  morphin.  The  pain  was 
in  the  center  of  the  abdomen  and  did  not  radiate.  He  remembers 
that  he  had  an  attack  hke  this  five  years  ago,  but  none  so  severe  since. 
At  that  time  he  was  exposed  to  lead  and  one  of  his  fellow-workmen 
had  lead-poisoning. 

Discussion. — From  a  history  like  this,  duodenal  ulcer  is  perhaps 
the  first  thought  that  enters  our  minds.  The  sudden  attack  of 
faintness  while  at  work  might  be  due  to  a  hemorrhage,  the  blood 
passing  into  the  bowel,  but  the  continuous  vomiting  and  low  blood- 
pressure  in  a  patient  completely  at  rest  and  not  suffering  any  further 
hemorrhage  (if,  indeed,  any  has  occurred)  is  not  characteristic  of 
peptic  ulcer.  The  negative  physical  examination  does  not  incline 
us  either  for  or  against  a  peptic  ulcer,  since  in  the  majority  of  ulcer 
cases  physical  examination  shows  nothing  of  any  importance. 

At  the   time  of  his  second  entrance  the  evidence  of  pigmenta- 


VERTIGO  165 

tion,  especially  in  the  mouth,  becomes  important.  Taking  this  in 
connection  with  the  low  blood-pressure,  the  cardiac  and  gastric  symp- 
toms unexplained  by  any  obvious  cardiac  or  gastric  lesion,  Addison's 
disease  seems  probable. 

Lead-poisoning,  however,  must  be  seriousiy  considered.  The 
cramps  of  which  this  patient  complains  are  fairly  typical  of  lead- 
coKc,  and  his  occupation  is  one  which  might  well  expose  him  to  the 
absorption  of  lead.  But  lead-poisoning,  when  it  affects  the  blood-pres- 
sure at  all,  is  apt  to  raise  it.  Moreover,  when  a  patient  is  put  at  rest 
and  all  possibility  of  lead  absorption  is  stopped,  he  almost  always 
shows  prompt  improvement.  There  was  no  such  gain  in  this  case.  Yet 
the  absence  of  lead  line  and  of  stippling  in  the  blood  does  not  exclude 
lead-poisoning.  This  is  a  matter  of  some  importance,  as  many 
early  cases  pass  unrecognized  in  our  clinics  because  the  physical 
examination  is  negative  in  these  two  respects. 

If  Addison's  disease  is  our  diagnosis,  the  vertigo  is  naturally 
to  be  explained  as  a  result  of  cerebral  anemia  from  low  blood- 
pressure. 

Outcome. — ^At  4  o'clock  on  the  morning  of  the  13  th  his  respira- 
tions became  very  slow  and  shallow  and  soon  after  he  died.  Autopsy 
No.  2657  showed  tuberculosis  of  the  adrenal  glands.  No  evidence  of 
tuberculosis  elsewhere  in  the  body.  Slight  chronic  pleuritis  and  peri- 
carditis. 

It  is  notable  in  this  case  that  so  marked  a  period  of  improvement 
took  place  in  a  patient  who  must  have  been  suffering  from  Addison's 
disease  from  the  beginning  of  his  symptoms.  Addison's  disease  is 
often  stated  to  be  progressive  in  its  course.  This  case  proves  the 
contrary. 

Case  60 

An  Italian  laborer  of  fifty-nine  entered  the  hospital  June  8,  191 1. 
He  has  previously  been  well  and  his  family  history  is  good.  He 
began  in  June,  19 10,  to  suffer  from  dizzy  spells.  In  the  first  one  he 
fell  and  was  unconscious  half  an  hour.  He  has  never  fainted  since, 
but  ever  since  then  has  had  a  tight  feeling  in  the  front  and  left  side 
of  the  head,  with  stiffness  about  the  muscles  of  the  neck  and  some 
numbness  in  the  neck  and  back.  At  times  he  is  also  very  dizzy  or, 
again,  he  has  failures  of  memory,  or  is  unable  to  tell  what  he  is  doing 
on  account  of  a  cloudy,  peculiar  sensation  in  his  head.  For  the  last 
six  months  his  appetite  has  not  been  good  and  his  eyesight  has  failed 
somewhat.     During  the  last  year  there  has  been  some  loss  of  power, 


l66  DIFFERENTIAL   DLA.GNOSIS 

together  with  pain  and  numbness  in  the  right  arm.  Nevertheless, 
he  has  worked  almost  steadily  until  entrance. 

Physical  examination  shows  fair  nutrition  and  marked  tanning 
of  the  skin.  The  pupils  are  equal,  circular,  and  react  well  to  light, 
but  sUghtly  to  distance.  The  left  epitrochlear  gland  is  palpable, 
otherwise  there  is  no  glandular  enlargement.  The  heart's  impulse 
extends  i  cm.  outside  the  nipple  line,  in  the  fifth  space.  The  sounds 
are  regular,  faint,  and  at  the  mitral  area  the  first  sound  is  accompanied 
by  a  blowing  murmur,  transmitted  over  the  whole  precordia.  The 
aortic  second  is  sharp  and  greater  than  the  pulmonic  second.  The 
tension  of  the  pulse  seems  to  be  somewhat  increased.  The  walls 
not  demonstrably  thickened.  Systolic  blood-pressure,  135  mm.  Hg. 
Blood  and  urine  normal.  Wassermann  reaction  negative.  Coarse 
moist  rales  are  heard  with  inspiration  and  expiration  over  both  lungs, 
especially  at  the  right  base.  The  right  shoulder  seems  to  be  a  Httle 
stiff.  The  grip  in  the  right  hand  is  somewhat  less  strong  than  in  the 
left.  The  elbow-jerks  and  wrist-jerks  are  obtained  on  each  side  and 
are  equal.     The  knee-jerks  and  plantars  are  normal. 

Discussion. — The  essential  points  in  the  case  seem  to  be  attacks 
of  vertigo  and  a  cloudy  mental  state  occurring  in  an  old  man  with 
increased  arm  reflexes,  peculiar  pupils,  and  diminished  power  in  the 
right  arm.  This  is  the  sort  of  case  to  which  we  are  accustomed  to 
attach  the  diagnosis  of  arteriosclerosis,  although  we  do  so  wholly  on 
the  history.  There  is  nothing  in  the  physical  examination  to  support 
such  a  befief.     Our  course  of  reasoning  is  something  as  follows: 

Arteriosclerosis  is  very  frequent  in  old  men.  An  Italian  at  fifty- 
nine  is  an  old  man.  The  symptoms  here  present  might  be  all  caused 
by  arteriosclerosis.  Therefore,  in  the  absence  of  any  positive  evi- 
dence of  any  other  disease,  it  is  best  to  guide  our  action  in  prognosis 
and  treatment  upon  the  hypothesis  of  arteriosclerosis. 

What  else  could  it  be?  Conceivably  it  might  be  dementia  paral- 
ytica, but  we  have  no  positive  evidence  of  that  disease,  and  the  pupils, 
though  abnormal,  are  not  those  ordinarily  associated  with  cerebral 
spinal  syphiHs.  The  Wassermann  reaction  is  negative,  there  are  no 
mental  changes,  and  no  defect  in  sphincteric  action. 

Could  it  be  syphilitic  meningitis?  Again  we  have  no  definite 
evidence,  and  such  a  disease  is  much  less  common  than  arteriosclerosis. 

Outcome. — He  stayed  in  the  hospital  only  a  few  days,  and  there 
seemed  to  be  little  that  we  could  do  for  him.  He  went  home  on  the 
13th  of  June  and  died  at  the  end  of  September. 


VERTIGO  167 

Case  61 

A  teamster  of  twenty-four  entered  the  hospital  August  12,  191 1. 
Three  weeks  ago  his  head  began  to  feel  queer,  contained  a  buzzing 
noise,  and  felt  unsteady.  Soon  after  appeared  dizzy  spells,  so  that 
he  could  hardly  keep  his  balance  while  walking,  because  the  objects 
around  him  wavered  and  swam  about.  He  staggers  and  falls,  always 
to  the  left.  Two  weeks  ago  he  had  to  give  up  work  and  go  to  bed. 
For  ten  days  he  has  had  frequent  severe  headaches,  beginning  in  the 
left  frontal  region  and  lasting  an  hour  or  so.  For  five  days  he  has 
vomited  about  once  a  day,  without  relation  to  food.  The  vomiting 
is  preceded  and  followed  for  about  half  an  hour  by  nausea.  He  has 
noticed  no  weakness,  no  change  in  sensation. 

Physical  examination  shows  good  nutrition,  pupils,  normal.  Nys- 
tagmus. No  other  ocular  defect  superficially.  Optic  atrophy  in  the 
right  eye.  Thorax  and  abdomen  negative.  The  left  plantar  reflex 
absent,  the  left  cremasteric  sluggish.  Superficial  abdominal  reflexes 
not  obtained.  Other  reflexes  normal.  Blood  and  urine  normal. 
Blood-pressure,  130  mm.  Hg.,  systolic;  90  mm.  Hg.,  diastolic.  No 
temperature  in  two  weeks'  observation.  Wassermann  reaction  nega- 
tive. Dr.  E.  W.  Taylor  suggested  aural  vertigo;  Dr.  John  Homans, 
cerebellar  tumor.  On  the  13th  the  left  knee-jerk  is  found  to  be  more 
active  than  the  right.  On  the  i6th  there  is  ankle-clonus  on  the  left 
and  a  plantar  reflex  suggesting  Babinski.  Ankle-jerk  increased. 
The  deep  reflexes  of  the  left  arm  increased.  Superficial  abdominal 
reflex  present  on  the  right;  absent  on  the  left.  A  thorough  examina- 
tion of  the  ears  shows  no  disease. 

Discussion. — A  severe  headache  and  vertigo  in  a  patient  of  twfenty- 
four,  unexplained  by  any  simple  or  obvious  cause,  makes  us  think  of 
cerebral  tumor.  In  this  case  the  vertigo  is  of  the  aural  or  cerebellar 
type,  that  is,  it  is  associated  with  staggering  in  a  certain  definite 
direction  and  always  the  same  direction.  Concomitant  and  reinforc- 
ing symptoms  are  the  vomiting,  nystagmus,  increase  of  deep  reflexes, 
diminution  of  the  superficial  reflexes,  and  optic  atrophy.  If  the 
trouble  .were  wholly  labyrinthine,  many  of  these  symptoms  would 
not  be  explicable.  On  the  other  hand,  there  are  no  symptoms  in  the 
case  that  could  not  be  explained  by  cerebral  tumor,  and  this  seems,  on 
the  whole,  the  most  reasonable  diagnosis.  Since  localizing  symptoms, 
most  of  them  concern  the  left  side;  we  may  suppose  that  the  trouble 
is  on  the  right  side  of  the  cerebellum. 

Outcome. — On  the  12th  of  September  the  occipital  region  was  de- 


1 68  DIFFERENTIAL  DIAGNOSIS 

compressed  with  considerable  difficulty,  as  the  skull  was  very  thick. 
Wlule  the  operation  was  going  on  the  blood-pressure  gradually  fell  to 
85  and  the  pulse  became  impalpable.  The  patient's  position  was  then 
changed,  and  the  respiration,  which  had  stopped,  improved.  The 
exposed  dura  was  tense  and  bulging,  but  was  not  opened.  After  the 
operation  he  did  very  poorly.  While  in  the  ward  respiration  sud- 
denly became  labored  and  irregular.  Cyanosis  supervened  and  the 
patient  died  of  respiratory  failure.  Autopsy  showed  a  cholesteatoma 
in  the  median  line  between  the  two  lobes  of  the  cerebellum,  but  not 
actually  in  the  cerebellar  tissue.  The  tumor  was  encapsulated  and 
about  the  size  of  a  fist. 

Case  62 

A  locomotive  inspector  of  forty-seven  entered  the  hospital  Novem- 
ber 9, 191 1.  The  patient's  mother  died  at  seventy-six  of  consumption; 
otherwise  the  family  history  is  excellent.  He  takes  a  glass  of  whisky 
once  a  day  and  smokes  a  pipe  incessantly.     He  denies  venereal  disease. 

Ten  days  ago  he  felt  as  well  as  ever,  but  as  he  started  to  go  home 
from  work  he  suddenly  felt  weak,  light  headed,  and  short  of  breath. 
Then  came  nausea  and  vomiting,  but  he  reached  home,  there  ate 
heartily,  and  went  to  sleep.  He  woke  very  tired,  and  while  walking  to 
work  the  next  day  he  felt  weak  and  vomited  again.  While  at  work 
that  day  he  had  several  giddy  spells  and  had  to  grasp  a  support  to 
prevent  himself  from  falling.  Every  day  since  that  time  he  has  had 
similar  experiences  and  a  constant  sense  of  fatigue.  He  vomits  only 
when  walking  to  or  from  his  work,  and  he  has  to  walk  very  slowly. 
He  needs  half  an  hour  to  cover  a  distance  which  he  formerly  did  in 
ten  minutes. 

Last  night,  for  the  first  time,  he  fell  during  one  of  his  giddy  spells 
and,  being  detected  in  this  by  his  foreman,  was  sent  to  the  hospital. 
He  did  not  lose  consciousness  and  had  nothing  Hke  an  aura.  He  has 
had  no  trouble  in  controlhng  his  sphincters  and  no  fever,  but  remembers 
four  days  ago  a  heavy  sweat.  During  the  ten  days  of  his  illness  he 
thinks  he  has  lost  14  pounds. 

Physical  examination  shows  a  thin,  pale  man,  lying  fiat  without 
dyspnea,  but  with  slight  cyanosis  of  the  mucous  membranes.  The 
pupils  are  circular,  equal,  and  react  normally.  There  is  no  glandular 
enlargement  and  no  lead  line.  Internal  viscera  negative.  Knee- 
jerks  not  obtained  even  with  reinforcement.  Ankle-jerks  slight, 
but  present.  The  range  of  the  temperature  is  shown  in  the  accompany- 
ing chart  (Fig.  64).     The  urine  averaged  45  ounces,  with  a  specific 


VERTIGO 


169 


gravity  of  1020,  a  very  slight  trace  of  albumin,  and  a  few  hyaline  casts. 
The  leukocyte  counts  are  as  follows:  November  9th,  6000;  November 
13th,  7000;  November  21st,  8000;  December  2d,  5500;  December  8th, 
8500;  December  nth,  11,000;  December  14th,  8000.  The  Wasser- 
mann  reaction  is  negative;  blood  culture  is  also  negative.  Widal 
reaction  is  positive  at  entrance,  but  the  case  did  not  seem  at  all 
typical  of  typhoid  fever,  as  there  is  no  prostration  and  no  rose  spots 
or  splenic  enlargement,  and  the  fever  is  often  higher  in  the  morning 
than  at  night;  in  fact,  this  is  the  rule  during  the  first  week  of  his 
stay  in  the  hospital.  The  Widal  reaction  is  recorded  as  follows: 
On  the  loth,  suggestive;  on  the  14th,  slightly  positive;  on  the  17th, 


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Fig.  64. — Chart  of  Case  62. 

positive;  on  the  29th,  suggestive.  On  the  29th  a  few  sharply  resound- 
ing rales  were  heard  at  the  base  of  each  lung,  and  from  that  time 
on  the  tendency  to  hypostasis  steadily  increased  and  the  respirations 
rose,  but  no  evidence  of  sohdification  was  made  out.  December  14th 
he  seemed  to  be  improving  and  the  outlook  for  recovery  seemed 
hopeful.  At  times  during  this  week  he  had  patches  of  crackUng  rales 
in  the  front  of  the  chest  without  any  signs  of  sohdification  and  without 
any  persistence  .in  a  single  site. 

Discussion. — The  history  gives  us  no  Hght  at  all  on  the  diagnosis. 
It  is  not  until  we  get  to  the  physical  examination  that  it  becomes 
obvious  that  we  are  deahng  with  some  sort  of  an  infectious  disease, 


lyo  DIFFERENTIAL  DIAGNOSIS 

probably  with  tj-phoid  fever,  since  we  have  a  continuous  pyrexia, 
low  white  count,  and  positive  Widal  reaction.  Against  typhoid  we 
have  mainly  the  fact  that  the  fever  is  higher  in  the  morning  than  at 
night.  I  do  not  remember  to  have  ever  seen  this  happen  in  typhoid 
fever.  On  the  other  hand,  I  have  often  seen  the  temperature  higher 
in  the  morning  than  at  night  in  cases  of  phthisis,  and  Dr.  James  A. 
Honeij  has  recently  reported  the  same  thing  in  leprosy.  The  posi- 
tive signs  of  t}^hoid,  such  as  enlarged  spleen,  rose  spots,  and  ty- 
phoid bacilli  in  the  blood-stream,  are  not  present  here,  but  they  are, 
as  we  know,  frequently  absent  in  demonstrable  typhoid  fever. 

Can  this  patient  have  a  sepsis  of  any  type?  There  is  nothing  to 
suggest  it,  and  no  evidence  of  a  focus  of  infection  or  of  any  source 
from  which  he  could  have  acquired  it.  Nevertheless,  we  must  admit 
that  sepsis  may  occur  without  our  being  able  to  discover  any  point 
of  entry  or  any  present  focus  of  infection. 

Tuberculosis  will  account  for  all  the  symptoms  except  for  the 
positive  Widal  reaction.  The  initial  and  persistent  cyanosis  and  the 
rising  respirations  suggest  the  miliary  form. 

As  I  remember  the  case,  the  majority  of  us  considered  it  one  of 
typhoid,  and  explained  the  vertigo  as  that  ordinarily  associated  with 
the  beginning  of  an  infectious  fever. 

Outcome. — He  died  on  the  i6th.  Autopsy  showed  miliary  tuber- 
culosis of  the  lungs,  liver,  spleen,  and  kidneys,  solitary  tubercle  of  the 
small  intestine,  obsolete  tuberculosis  of  the  bronchial  lymphatic  glands 
and  right  lung,  chronic  pleuritis  of  the  right. 

Case  63 

A  box  maker  of  forty-three  entered  the  hospital  November  14, 
191 1.  The  patient's  father  died  at  eighty-four  of  gastric  cancer. 
Otherwise  the  family  history  is  good.  The  patient  denies  alcohol  and 
venereal  disease,  and,  though  always  dizzy,  has  been  well  and  strong 
all  his  life.  Sixteen  months  ago  dizzy  spells  began  to  bother  him 
increasingly  and  are  now  his  chief  complaint.  They  begin  with  a 
hissing  sound  in  his  right  ear.  A  few  minutes  after  this  things  begin 
to  spin  round  in  the  horizontal  plane,  from  left  to  right.  This  lasts 
about  two  minutes,  and  unless  he  sits  down  or  takes  hold  of  some  sup- 
port he  invariably  twists  round  from  left  to  right  and  tumbles  upon 
his  right  side.  The  noise  in  the  ear  stops  immediately  before  the 
vertigo  does.  After  an  attack  he  perspires,  vomits,  and  is  weak. 
Within  fifteen  minutes  he  is  all  right  again.  He  never  loses  con- 
sciousness. 


VERTIGO  171 

The  attacks  have  come  at  various  hours  in  the  daytime,  never 
at  night.  The  early  attacks  were  separated  by  a  week  or  so,  but  for 
the  last  year  he  has  had  them  every  few  days  and  sometimes  two  or 
three  in  a  day. 

Eight  months  ago,  after  a  severe  attack,  he  was  semiconscious 
for  some  hours,  and  since  then  he  has  not  felt  able  to  work  and  has 
gradually  come  to  notice  a  deafness  in  the  right  ear. 

Three  months  ago  he  noticed  cloudiness  and  specks  before  his  eyes 
when  he  raised  his  head  after  stooping.  Glasses  gave  him  no  relief, 
though  they  improved  his  vision.  He  notices,  however,  that  if  he 
takes  off  his  glasses  while  standing  or  sitting  he  sometimes  has  an 
attack  of  vertigo.  In  fact,  this  is  the  only  thing  that  he  knows  of  as 
capable  of  bringing  on  an  attack.  He  has  had  a  few  attacks  of  sharp 
frontal  headache,  and  for  the  last  three  months  a  feeling  of  fulness  or 
pressure,  almost  constant,  in  the  right  half  of  the  head. 

Every  week  or  so  and  sometimes  for  several  days  in  succession 
he  has  a  discomfort,  compared  to  a  sense  of  a  hot  stone  below  his 
right  ribs  in  front.  This  comes  most  often  at  night  and  has  no  rela- 
tion to  meals,  but  he  thinks  he  can  feel  a  lump  in  the  seat  of  discom- 
fort at  the  time  of  these  attacks,  which,  however,  bothers  him  very 
little.  His  bowels  are  very  constipated  and  require  medicine  daily. 
His  best  weight,  eighteen  months  ago,  122  pounds;  now,  112  pounds. 
He  has  no  further  complaints. 

Physical  examination  shows  poor  nutrition,  normal  pupils  and 
reflexes,  no  nystagmus,  no  abnormalities  in  the  internal  viscera, 
normal  blood,  urine,  and  blood-pressure;  no  fever.  The  diagnosis 
at  entrance  was  enteroptosis,  with  a  question  of  cancer  near  the 
cecum.  On  the  iSthhe  was  sent  to  the  Massachusetts  Charitable  Eye 
and  Ear  Infirmary,  where  examination  showed  that  the  hearing  in 
both  ears  was  excellent.  Tests  for  labyrinth  disease  showed  a  slug- 
gish reaction  in  all  three  directions,  but  nothing  positive  enough  to 
point  definitely  to  either  ear  or  to  suggest  an  operation.  The  Wasser- 
mann  reaction  was  negative.  The  fundus  oculi  normal.  A  neurologic 
consultant  believed  the  case  to  be  Meniere's  disease,  despite  the 
report  of  the  aural  consultant.  At  the  advice  of  the  former,  25  c.c.  of 
spinal  fluid  was  removed  by  lumbar  puncture.  The  fluid  was  limpid 
and  came  out  under  moderate  pressure.  The  patient  felt  imme- 
diately relieved  from  a  sense  of  tightness  in  the  right  side  of  his  head 
and  from  the  sharp  pumping  in  his  ear  with  each  heart-beat,  but  next 
day  he  vomited  and  had  a  severe  attack  on  getting  up.  These  attacks 
continued  daily,  and  after  the  spinal  puncture  he  seemed  distinctly 


k 

^ 


172  DIFFERENTIAL  DIAGNOSIS 

worse,  in  that  a  new  set  of  sensations  were  now  complained  of,  radiat- 
ing from  the  point  of  lumbar  puncture.  High-frequency  electricity 
and  hydrotherapy  were  given  during  the  last  week  of  his  stay  in  the 
hospital,  whence  he  was  discharged  December  31st. 

Discussion. — This  patient  says  that  he  has  always  been  dizzy. 
A  statement  like  this  generally  means  a  neurotic  patient,  and  that, 
naturally,  is  our  first  impression  of  this  case,  but  when  we  find  that 
he  has  the  t}-pical  Meniere's  complex,  we  may  properly  doubt  our  first 
guess.  It  must  be  admitted  that  INIeniere's  complex  has  been  shown  to 
exist  in  patients  seemingly  free  from  any  aural  disease  and  appar- 
ently belonging  in  the  neurotic  group.  The  results  of  aural  ex- 
amination and  of  lumbar  puncture  go  to  support  the  idea  that  we  are 
dealing  in  this  case  with  what  has  been  called  a  pseudo-Meniere's 
complex.  This  is  further  suggested  by  the  fact  that  after  lumbar 
puncture  the  patient  experienced  a  new  set  of  symptoms,  radiating 
from  the  point  of  puncture  and  apparently  due  to  the  strongly  un- 
pleasant effect  made  upon  his  mind  by  that  operation. 

The  gastric  symptoms  may  well  be  interpreted  as  those  of  a 
nervous  hypochlorhydria. 

Outcome. — June  17,  1914,  the  patient  writes  that  he  is  about  the 
same,  that  he  has  had  several  of  the  dizzy  spells,  the  last  four  weeks 
ago.  He  complains,  moreover,  of  a  profuse  flow  of  perspiration  in 
the  right  side  of  his  head.  His  appetite  is  good,  weight  unchanged, 
and  general  health  apparently  very  fair. 

Case  64 

A  housewife  of  twenty-nine  entered  the  hospital  May  13,  191 2. 
For  six  months  the  patient  has  been  troubled  much  by  spells  of  dizzi- 
ness and  by  severe  temporal  headaches.  Her  eyesight  has  always 
been  unsatisfactory.  For  the  past  week  she  has  been  in  bed  most  of 
the  time  on  account  of  weakness  and  sore  throat.  She  has  fainted 
once  or  twice,  and  vomited  once  a  week  ago.  She  has  four  children, 
living  and  well,  but  since  the  last  child  has  had  four  miscarriages. 
In  August,  1909,  small  sores  came  out  upon  her  arms  and  legs,  and  in 
November  a  general  eruption  on  the  face  and  neck. 

Her  appetite,  bowels,  and  sleep  are  normal.  Her  hands  and  feet 
feel  numb  a  good  deal  of  the  time.  She  has  no  cough,  dyspnea,  or 
edema.     For  the  last  two  months  her  menstruation  has  been  absent. 

On  physical  examination  the  patient  is  well  nourished,  drowsy, 
and  slow  mentally.  She  complains  and  cries  out,  but  cannot  locate 
pain  anywhere.      The  skin  shows  ichthyosis.      The  pupils  are  irreg- 


VERTIGO  173 

ular,  the  right  larger  than  the  left,  both  reacting  sluggishly  to  light. 
The  uvula  is  absent  and  the  surrounding  area  has  a  ragged  edge. 
The  internal  viscera  show  nothing  abnormal  and  the  reflexes  are 
negative.  The  lower  legs  are  covered  with  depressed  circular  scars, 
I  to  i|  cm.  in  diameter,  some  white,  some  red,  some  slightly  crusted. 

In  the  wards  the  patient  was  constantly  distressed  by  vertigo 
and  headache  when  not  sleeping  or  drowsing.  When  spoken  to  she 
answered  in  a  weak,  high-pitched,  whining  voice.  Her  mental  proc- 
esses were  slow.     The  Wassermann  reaction  was  weakly  positive. 

Discussion. — The  history  is  not  in  any  way  definitive.  The  four 
miscarriages  may  well  have  been  self-induced.  We  cannot  justly 
take  them  as  evidences  of  syphihs. 

But  when  we  come  to  the  physical  examination  and  find  Argyll- 
Robertson  pupils,  a  throat  strongly  suggestive  of  syphilitic  ulcera- 
tion, and  a  weakly  positive  Wassermann  reaction,  I  do  not  see  how  we 
can  fail  to  believe  that  syphihs  is  the  most  probable  diagnosis.  The 
nature  of  the  scars  upon  the  lower  legs  is  not  clear  from  the  descrip- 
tion here  given,  but  they  are  perfectly  consistent  with  a  diagnosis  of 
syphihs.  If  this  be  correct,  the  vertigo  is  to  be  explained  as  that 
accompanying  the  earlier  state  of  an  infectious  process.  Such  vertigo 
is  especially  common  at  the  beginning  of  this  particular  disease,  per- 
haps because  it  so  early  involves  the  cerebral  spinal  system. 

Outcome. — On  the  2 2d  and  the  28th  ^  gram  of  salvarsan  was  given 
intravenously.  By  the  30th  she  showed  marked  improvement,  was 
bright,  smiling,  free  from  headache,  and  eating  well.  The  voice  had 
lost  the  distressing  whine  and  she  was  able  to  sit  up  all  day.  On  the 
3d  and  loth  of  June  salvarsan  was  given  as  before.  On  the  nth  the 
soft  palate  was  entirely  healed,  the  Wassermann  reaction  negative. 

Case  65 

A  machinist  of  forty-six  entered  the  hospital  August  7,  1912. 
The  patient's  father  died  of  tuberculosis  at  sixty-three,  otherwise 
his  family  history  is  excellent.  The  patient  had  bloody  dysentery 
at  eighteen,  and  for  many  years  has  had  indigestion,  with  gas  and  sour 
stomach,  unless  he  is  careful  of  his  diet.  He  denies  venereal  disease. 
Twenty-seven  years  ago  his  hearing  began  gradually  to  be  impaired 
and  this  trouble  has  progressed  until  now  he  is  stone  deaf.  He  also 
has  a  sense  of  pressure  in  his  head  and  noises  in  his  ears,  especially 
during  the  last  few  weeks. 

For  two  years  he  has  had  occasional  attacks  of  dizziness  and 
vomiting,  attributed  to  and  treated  for  stomach  trouble,  and  never 


174  DIFFERENTIAL  DIAGNOSIS 

occurring  at  his  work,  but  always  upon  Sundays  and  holidays. 
During  the  last  few  weeks  he  has  felt  light  headed  a  good  deal  of 
the  time,  but  without  vomiting.  He  always  feels  better  when  lying 
down,  and  apparently  can  sometimes  stave  off  an  attack  by  lying 
down  and  going  to  sleep. 

Today,  while  on  a  trip  to  Revere,  he  was  taken,  on  the  electric 
car,  with  severe  vertigo,  so  that  he  staggered  like  a  drunken  man. 
He  leaned  against  a  fence  and  vomited;  later  he  was  brought  to  the 
hospital. 

Physical  examination  was  entirely  negative  except  for  the  deaf- 
ness. Urine  and  blood-pressure  were  within  normal  limits.  An 
aural  consultant  found  otosclerosis  and  considered  disease  of  the 
labyrinth  possible.     The  Wassermann  reaction  was  negative. 

Discussion. — The  patient's  deafness  makes  it  natural  to  attribute 
his  vertigo  to  aural  trouble.  Why  he  should  have  had  vertigo  at 
first  only  on  Sundays  and  holidays  I  have  no  idea.  People  are  more 
apt  to  overeat  and  overdrink  at  these  times,  and  this  fact  may  have 
led  his  local  physician  to  treat  him  for  stomach  trouble.  One 
may  blame  the  general  practitioner  in  a  case  like  this  for  giving 
treatment  directed  to  the  stomach  when  there  is  good  reason  to  sup- 
pose the  ears  to  be  at  fault,  but,  after  all,  we  cannot  say  that  any 
harm  results  therefrom,  since  the  aural  specialist  can  almost  never  do 
anything  to  benefit  the  patient,  who  finds  the  latter's  discouraging 
prognosis  by  no  means  palatable.  The  patient  always  prefers  to 
refer  the  vertigo  to  his  stomach.  It  is  very  natural,  therefore,  to 
accept  his  view  of  things  and  treat  him  accordingly.  Nevertheless, 
if  we  want  the  truth,  we  have  no  right  to  allow  the  patient  to  be 
without  the  services  of  an  expert  aurist. 

Outcome. — For  more  thorough  examination  he  was  transferred  to 
the  Eye  and  Ear  Infirmary,  where  positive  evidence  of  labyrinthitis 
was  found. 


CHAPTER   III 

DIARRHEA 

CAUSES  AND  TYPES  OF  DIARRHEA  IN  ADULT  LIFE 

I  UNDERTOOK  recently  a  fresh  study  of  this  ancient  problem,  with 
the  collaboration  of  Dr.  Haven  Emerson,  of  New  York,  beginning  with 
the  necropsy  records  of  Belle vue  Hospital  in  New  York  and  the 
Massachusetts  General  Hospital  in  Boston.  In  the  latter  institu- 
tion I  examined  3000  of  the  necropsy  records,  searching  for  lesions 
ordinarily  supposed  to  produce  diarrhea.  I  then  traced  the  cases 
showing  these  legions  back  to  the  clinical  records,  trying  to  ascertain 
first  whether  the  lesions  actually  produced  diarrhea,  and  if  so,  in  what 
proportion  of  cases;  second,  whether  any  special  type  of  symptoms  or 
of  discharges  was  associated  with  any  special  lesion  of  the  intestine, 
the  endeavor  being  to  mark  out  clinical  types  so  far  as  this  was  pos- 
sible. Finally,  I  reviewed  the  results  of  treatment  both  in  necrop- 
sied  cases  and  in  a  considerable  series  of  cases  which  did  not  come  to 
necropsy,  and  endeavored  to  estimate  the  value  of  the  different 
methods  used. 

For  various  reasons  I  have  excluded  from  this  study  certain  dis- 
eases often  associated  with  diarrhea.  I  have  taken  no  account  of  the 
cases  of  typhoid  fever,  partly  because  the  relation  of  this  disease  to 
diarrhea  has  already  been  thoroughly  studied  in  large  groups  of  cases, 
and,  second,  because  I  was  anxious  to  get  some  idea  of  the  relative 
frequency  of  the  different  diseases  showing  this  symptom,  and  I  am 
well  aware  that  the  number  of  persons  sick  with  t3^hoid  in  these  two 
hospitals  was  not  a  fair  sample  of  the  number  of  cases  of  this  disease 
existing  in  the  community  outside,  since  cases  of  typhoid  are  quite 
abnormally  collected  from  large  areas  in  hospitals  such  as  that  in 
which  I  have  pursued  my  studies.  The  parasitic  diarrheas  have  also 
been  excluded  because  of  the  small  number  of  these  cases  available  in 
Boston  or  New  York.  I  have  made  no  effort  to  study  the  cases  of 
mercurial  or  arsenical  poisoning  or  cases  of  dysentery  due  to  organisms 
of  the  Shiga  type,  or  other  organisms  closely  allied  to  it.  I  have  also 
excluded  all  cases  occurring  in  persons  under  sixteen  years  of  age. 
Leaving  out  the  types  just  mentioned,  we  have  left  640  cases  of  the 
varieties  ranged  in  Table  i. 

175 


176  DEFFERENTL\L  DIAGNOSIS 

TABLE    I— RELATIVE   FREQUENCY   OF   DISEASES    CAUSING   DIARRHEA 
IN  ADULTS— MASSACHUSETTS   GENERAL  HOSPITAL,   1905-1912 

Acute  enteritis  and  unknowTi  (acute)  causes — clinical  cases 244 

Acute  enteritis — necropsied  cases: 

"Primary".. 9 

Secondary'  [with  and  without  intestinal  lesions]  to: 

Nephritic   lesions 10 

Cardiac  lesions 2 

Cardiorena  lesions 2 

Arteriosclerotic  lesions 3 

Acute  infectious  lesions 5 

Various  acute  and  chronic  conditions 10 

Intussusception i 

42 

Acute  enteritis — total 286 

Chronic  enteritis  and  unknow-n  (chronic)  causes — clinical  cases 139 

Chronic  enteritis,  necropsied  cases: 

"Primary,"  i.  e.,  of  unknown  cause 8 

Secondary  to: 

Cardiac 7 

Renal i 

Cardiorenal i 

Various  chronic  conditions 2 

19 
Chronic  enteritis — total 158 

Cancer  of  bowel 52 

Pernicious  anemia 34 

Mucous  colitis 32 

Exophthalmic  goiter 25 

Nervous  diarrhea 17 

Tuberculosis  of  bowel 15 

Amebic  dysentery 14 

Fat  intolerance 7 

Total ' 640 

DIFFICULTY  OF  DISTINGUISHING  ACUTE  FROM  CHRONIC 
ENTERITIS  AND  COLITIS 

It  is  clearly  desirable  to  distinguish  the  acute  from  the  chronic 
cases,  but  this  I  have  found  unexpectedly  difficult.  The  intes- 
tine is  like  the  kidney,  in  that  a  long-standing  disease  may  show- 
clinical  symptoms  only  now  and  then,  presenting  itself  suddenly 
under  the  guise  of  an  acute  disease.  Just  as  the  acute  exacerbations 
of  chronic  nephritis  appear  under  the  guise  of  an  acute  nephritis,  so 
the  acute  exacerbations  of  a  chronic  colitis  (due  to  amobae  or  other 
causes)  often  appear  with  all  the  evidences  of  acute  disease,  run  a  short 
course  and  subside,  though  we  have  good  reason  to  suppose  that  the 
intestine,  Hke  the  kidney,  remains  diseased  throughout  long  symptom- 


Relative  Frequency  of  the  Common  Causes  of 
Diarrhea  in  Adults 


MASSACHUSETTS  GENERAL   HOSPITAL,   1905-1912 


ACUTE   ENTERITIS 
CHRONIC    ENTERITIS   , 
CANCER   OF   BOWEL 
PERNICIOUS  ANEMIA     * 
MUCOUS   COLITIS 
EXOPHTHALMIC   GOITER 
NERVOUS   DIARRHEA 
TUBERCULOSIS  OF   BOWEL 
AMEBIC    DYSENTERY 
FAT  INTOLERANCE 

TOTAL 


CAUSE  UNKNOWN,   253. 


CAUSE  UNKNOWN,   147.     KNOWN,  11. 


KNOWN,  33. 


286 

158 

52 

34 

32 

25 

17 

15 

14 

7 

640 


-^"a 


Vol.  11—12 


177 


178  DIFFERENTIAL  DIAGNOSIS 

less  periods.  Only  by  following  individual  cases  in  large  numbers  and 
over  a  long  period  of  time  would  it  be  possible  to  ascertain  whether  a 
diarrhea  which  appears  to  be  evidence  of  an  acute  disease  is  really 
such,  or  merely  one  of  the  exacerbations  of  a  chronic  process.  Since 
I  have  been  unable  to  follow  any  large  number  of  cases  in  this  way  over 
a  long  period,  I  have  not  found  it  possible  in  this  study  sharply  to 
separate  the  acute  from  the  chronic  cases. 

Further,  the  attempt  to  classify  all  the  long-standing  diarrheas  as 
due  to  organic  intestinal  disease  and  all  the  acute  diarrheas  as  func- 
tional, breaks  down,  both  for  the  reason  just  indicated  and  because  in 
some  cases  a  purely  functional  disturbance  hardened  into  a  habit  may 
produce  a  long-standing  diarrhea,  though  organic  disease  is  demon- 
strably absent. 

CAUSES  OF  DIARRHEA 

"Indiscretions  in  diet"  have  long  been  blamed  for  a  large  propor- 
tion of  the  brief  diarrheas  occurring  in  adults  as  well  as  in  children. 
There  is  no  reason  to  doubt  that  these  indiscretions  are  in  a  certain 
nimiber  of  cases  responsible,  but  a  careful  analysis  of  the  records 
shows  that  many  patients  suffering  from  precisely  the  same  symp- 
toms as  those  supposedly  due  to  indiscretions  of  diet  have,  in  fact, 
committed  no  such  indiscretions  and  eaten  nothing  unusual.  These 
patients  are  often  badgered  about  dietetic  history  until  some  damag- 
ing admission  about  diet  is  with  difficulty  extracted  from  them,  the 
physician  feeling  it  incumbent  on  him  to  find  something  wrong  in  the 
diet  at  all  hazards.  By  leading  questions,  almost  any  patient  can  be 
induced  to  assert  that  he  has  eaten  something  unusual  or  deleterious 
within  a  more  or  less  extended  period  previous  to  the  beginning  of  his 
sjonptoms.  But  if  we  are  fair  and  do  not  try  to  prejudge  the  case, 
we  must  admit  that  the  number  of  cases  in  which  faulty  diet  is  ob' 
viously  the  cause  of  an  acute  diarrhea  is  much  smaller  than  is  ordinarily 
supposed. 

Among  a  group  of  89  patients  suffering  from  acute  benign  diar- 
rhea, presenting  in  the  stools  no  evidence  of  bowel  ulceration  and 
recovering  within  from  ten  to  fourteen  days,  41  patients  ascribed  the 
trouble  to  some  supposed  indiscretion  in  diet  or  to  some  food  believed 
to  have  been  poisonous,  while  48  patients,  exhibiting  precisely  the 
same  symptoms,  signs,  and  course,  remembered  no  dietetic  cause  for 
their  trouble  and,  indeed,  no  obvious  cause  of  any  kind. 

In  but  few  cases  out  of  this  whole  series  was  there  any  convincing 
evidence  that  the  patient  and  other  persons  had  partaken  of  a  certain 
food  and  that  all  were  similarly  attacked  by  diarrhea,  while  other 


DIARRHEA 


179 


persons  under  the  same  conditions,  except  for  abstention  from  that  par- 
ticular food,  remained  well.  A  study  of  the  cHnical  records  has  con- 
vinced me  that  even  in  the  group  of  cases  labeled  by  the  patient  or  by 
his  physician  as  due  to  indiscretion  in  diet,  this  diagnosis  is  often 
retrospective  and  made  simply  for  the  reason  that  other  cause  could 
not  be  found. 

Ptomain-poisoning  is  one  of  the  commonest  and  one  of  the  most 
popular  and  fashionable  diagnoses  of  the  day  among  a  certain  class  of 
practitioners.  Yet  this  diagnosis  will  seldom  stand  criticism.  Many 
of  the  cases  to  which  this  name  is  given  turn  out  to  be  appendicitis, 
gall-stones,  intestinal  obstruction,  pancreatitis,  a  gastric  crisis  in 
tabes,  lead-poisoning,  and  other  diseases  having  nothing  to  do  with 
ptomains.  In  another  group  of  cases  the  evidence  points  simply  to 
an  acute  diarrhea  of  unknown  origin  which  is  labeled  "ptomain- 
poisoning"  presumably  because  of  the  impressive  sound  of  the  term. 
The  number  of  cases  in  which  a  chemical  poison  properly  to  be  called 
a  ptomain  or  leukomain  has  been  isolated  from  the  food  taken  by  the 
patient  is  almost  negligible.  In  my  series  there  are  no  cases  at  all  of 
this  kind.  I  have  not  found  a  single  case  which  deserves  the  term 
"ptomain-poisoning,"  although  there  were  cases  in  which  the  diarrhea 
seemed  attributable,  with  reasonable  certainty,  to  something  wrong 
in  the  food.  In  these  cases  the  much  vaguer  and  less  high-sounding 
term  of  "food  poisoning"  seems  to  me  more  proper. 

I  have  merged  in  a  single  group  a  large  number  of  cases  variously 
designated  on  the  clinical  records  because  there  seemed  to  be  no  good 
reason  for  the  employment  of  the  different  terms  such  as  dysentery, 
gastro-enteritis,  enterocolitis,  colitis,  etc.  To  the  same  group  of  cases, 
now  one,  now  another  of  these  terms  is  applied  without  any  clear  reason, 
according  to  the  taste  and  fancy  of  the  individual  physician. 

In  a  small  group  of  cases,  only  7,  in  the  Massachusetts  General 
Hospital  series  during  a  period  covering  the  years  from  1895  to  date, 
there  has  seemed  to  be  a  genuine  intolerance  of  the  intestine  for  one 
or  another  foodstuff,  chiefly /a^.  Intolerance  for  a  protein  or  a  carbo- 
hydrate was  very  rarely  identified,  but  in  the  small  group  of  cases 
previously  referred  to,  an  excess  of  fat  was  present  in  the  stools  on 
ordinary  diet,  and  when  a  diet  free  from  fat  was  given,  the  diarrhea 
ceased.  In  none  of  these  cases  was  there  any  definite  evidence  of 
pancreatic  disease  or  of  any  other  organic  cause  for  the  anomaly; 
indeed,  no  cases  of  diarrhea  definitely  to  be  referred  to  pancreatic  dis- 
ease were  studied  in  this  series. 

Passive  congestion  of  the  intestine  is  not  a  cause  of  diarrhea.    This 


i8o 


DIFFERENTLA.L   DIAGNOSIS 


lesion  was  present  in  a  large  number  of  the  cases  of  my  series  in 
which  necropsy  was  performed,  but  was  seldom  associated  with 
diarrhea.  Thus  in  88  cases  of  badly  compensated  cardiac  lesions 
producing  death  with  dropsy  and  general  stasis,  only  8  patients  had 
diarrhea  at  any  time.  In  7  other  cases  of  general  cardiac  stasis  the 
intestine  showed  postmortem  the  lesions  of  enteritis,  3  of  the  ulcera- 
tive and  4  of  the  diphtheric  type,  but  in  only  one  of  these  7  cases  was 
there  any  diarrhea.  Among  13  patients  with  chronic  nephritis,  dying 
by  cardiac  failure  with  general  passive  congestion  of  all  the  organs, 
not  one  had  diarrhea.  Constipation  is  the  rule  in  cardiac  or  cardio- 
renal  disease  with  stasis. 

Tuberculosis  of  the  intestine  is  a  favorite  diagnosis  among  general 
practitioners  confronted  by  intractable  and  chronic  cases  of  diarrhea. 
In  my  experience  such  a  diagnosis  is  almost  never  warranted,  for  it  is 
likely  to  be  made  in  patients  showing  no  pulmonary  lesions  of  tuber- 
culosis and  despite  the  well-known  fact  that  tuberculous  enteritis 
almost  never  occurs  except  as  a  complication  of  phthisis.  A  striking 
result  of  our  studies  is  this :  Even  when  there  is  a  demonstrable  tuber- 
culosis of  the  intestine  (complicating  pulmonary  disease)  diarrhea 
occurs  in  only  i  case  out  of  3.  Thus  in  only  10  out  of  31  cases 
of  tuberculous  enterocolitis  which  came  to  necropsy  at  the  Massa- 
chusetts General  Hospital  (32  per  cent.)  and  in  only  29  out  of  100 
similar  cases  studied  postmortem  at  the  Belle vue  Hospital  (29  per 
cent.)  was  diarrhea  present.  The  two  series  of  cases  here  support 
each  other  in  a  very  striking  way  (Table  2). 

TABLE     2.— RELATIVE     FREQUENCY     OF     CERTAIN     FATAL     DISEASES 
ASSOCIATED   WTTH   DIARRHEA    (6000   NECROPSIES) 


_  ,,           TT       •      Massachusetts 
Bellevue  Hospi-         _,           ,  .,, 
,                              General  Hos- 

tal,  3000     ne-           .     , 

pital,         ^000 
cropsies.                                 . 

necropsies. 

Per   cent,    hav- 
ing diarrhea. 

Disease. 

u 

0 
H 

Number     of 
cases       of 
diarrhea. 

0 

5 
0 

Number     of 
cases       of 
diarrhea. 

0 
X 

Massachu- 
setts Gen. 
Hospital. 

Acute  and  chronic  enteritis  (unknown  cause) 
Cancer  of  colon 

ml 

18 

100 

71 

45 

4 

29 

II 

71 
64 
31 

35 

32 
20 
10 

4 

40 
22 
29 

15 

45 
32 
32 

II 

Tuberculosis  of  intestine 

Tuberculosis  of  the  lungs;  intestine  not  dis- 
eased   

^  seventy  classified  as  acute  postmortem;  25  of  these  had  diarrhea.     Forty-one  classi- 
fied as  chronic  postmortem;  20  of  these  had  diarrhea. 


DIARRHEA  l8l 

Even  when  diarrhea  occurs  in  patients  suffering  from  distinct 
tuberculosis  of  the  lungs,  one  is  by  no  means  certain  that  the  flux  is 
due  to  intestinal  tuberculosis,  for  diarrhea  is  nearly  half  as  common 
in  cases  of  pulmonary  tuberculosis  without  intestinal  lesions  as  in 
cases  with  these  lesions.  Thus  in  io6  cases  of  pulmonary  tuberculosis 
studied  postmortem  at  the  two  hospitals  referred  to,  15,  or  14  per  cent., 
had  diarrhea,  although  the  intestines  showed  no  lesions  whatever. 
All  this  emphasizes  the  fact  further  to  be  insisted  on  that  even  when 
intestinal  ulcerations  are  present  in  a  case  of  diarrhea  we  are  by  no 
means  certain  that  the  ulcerations  cause  the  diarrhea. 

Cancer  of  the  intestine  was  studied  in  159  patients,  postmortem 
or  after  operation,  at  the  Massachusetts  General  Hospital,  and  in  18 
patients  postmortem  at  the  Bellevue  Hospital.  The  percentage  of 
diarrhea  in  these  cases,  taken  as  a  whole,  is  almost  identical  with  that 
found  in  tuberculous  enteritis.  Thus  52,  or  32  per  cent.,  of  the  Massa- 
chusetts General  Hospital  cases  showed  a  diarrhea  either  steadily  or 
intermittently,  while  22  per  cent,  of  the  Bellevue  cases  showed  the 
same  symptom.  Contrary  to  the  accepted  idea  on  this  subject,  I 
did  not  find  that  diarrhea  was  any  commoner  in  cases  involving  the 
lower  part  of  the  intestine  than  in  those  involving  the  upper  part. 
Thus  in  43  cases  of  cancer  of  the  rectum,  diarrhea  was  present  in  37 
per  cent.,  while  in  67  cases  involving  the  hepatic  flexure,  the  ascend- 
ing colon,  or  the  cecum,  diarrhea  was  present  in  41  per  cent.  In  32 
cases  involving  the  intermediate  portion  of  the  colon,  including  the 
transverse  colon,  the  splenic  flexure,  and  the  descending  colon  (above 
the  sigmoid),  diarrhea  was  present  in  only  18  per  cent. 

In  chronic  renal  disease,  diarrheas  of  a  supposedly  compensatory 
type  are  often  said  to  occur.  My  studies  did  not  tend  to  confirm  this 
supposition,  for  in  72  cases  of  chronic  nephritis  diarrhea  was  present 
only  II  times  either  in  the  history  previous  to  hospital  treatment  or 
during  that  treatment. 

Intussusception  has  for  many  years  been  associated  in  text-books 
with  a  bloody  diarrhea  and  been  supposed  to  differ  thereby  from  other 
types  of  intestinal  obstruction.  This  idea  was  borne  out  only  to  a 
limited  extent  in  the  cases  studied  in  the  present  series,  for  only  3  out 
of  10  showed  any  diarrhea  at  all. 

I  have  had  no  opportunity  to  advance  my  knowledge  on  the 
subject  of  so-called  morning  diarrheas,  the  association  of  which  with 
achylia  gastrica  has  recently  been  referred  to.  Such  cases  are  ordinar- 
ily too  mild  to  need  hospital  treatment  and,  therefore,  did  not  come 
within  my  study.     My  experience,  however,  with  similar  cases  in 


l82  DIFFERENTIAL  DIAGNOSIS 

private  practice  confirms  that  of  others,  in  that  I  have  frequently- 
found  that  hydrochloric  acid  is  absent  from  the  gastric  contents  of 
such  patients.  The  special  treatment  of  this  class  of  cases  will  be 
referred  to  latqr. 

Closely  associated  with  these,  according  to  my  belief,  is  the  type 
known  as  nervous  diarrhea  or  simple  hyperperistalsis.  Presumably, 
there  is  some  connection  here  between  the  hyperperistalsis  and  low 
blood-pressure  in  the  peripheral  blood-vessels  with  vasodilatation  in 
the  splanchnic  area.  The  feeble  rapid  heart  and  the  tendency  to 
faintness  in  such  cases  goes  to  strengthen  this  supposition. 

An  important  group  of  cases,  not  very  numerous,  fortunately  for 
us,  but  very  obstinate  and  mysterious,  are  those  associated  with 
intestinal  ulceration  of  unknown  cause.  Many  of  these  cases  are  de- 
monstrably non-amebic  and  not  due  to  infection  by  any  known  type 
of  micro-organism.  Some  of  them  bear  the  marks  of  infectious  dis- 
ease— fever,  leukocytosis,  and  albuminuria.  In  others  there  is  no 
such  evidence.  The  diagnosis  is  made  from  the  condition  of  the 
stools  (see  hereafter)  or  by  proctoscopy.  Sixty  cases  of  ulcerative 
colitis  of  this  kind  were  studied  at  the  Massachusetts  General  Hospital, 
beginning  with  the  necropsy  record  and  following  the  case  back  into 
the  clinical  history.  One  hundred  and  eleven  similar  cases  were 
studied  at  Bellevue  Hospital.  In  55  per  cent,  of  the  Massachusetts 
General  Hospital  cases  and  60  per  cent,  of  the  Bellevue  cases  diarrhea 
was  absent,  and  the  diagnosis  of  intestinal  ulceration  or  ulcerative 
colitis  was  often  quite  unsuspected  before  necropsy.  Even  when  the 
colon  is  deeply  and  universally  ulcerated,  "hanging  in  rags,"  as  one  of 
my  colleagues  expressed  it,  the  bowels  may  be  constipated  throughout 
the  disease.  Although  there  is  nothing  new  about  this  statement, 
I  desire  to  emphasize  it  afresh,  since  there  is  so  strong  a  tendency  to 
use  the  words  diarrhea  and  enteritis  as  synonymous. 

In  cases  of  enteritis  without  diarrhea  the  diagnosis  is,  so  far  as  I 
can  see,  impossible,  unless  something  suggests  proctoscopy.  There 
may  be  no  local  tenderness  in  the  abdomen  and  nothing  whatever  to 
indicate  the  disease.  This  silence  is  only  what  one  might  have  ex- 
pected from  the  analogy  of  typhoidal  and  tuberculous  ulcerations, 
which  produce  in  the  great  majority  of  cases  constipation  rather  than 
diarrhea.  Thus  in  only  17  per  cent,  of  the  1495  cases  of  typhoid 
analyzed  in  Osier's  "Modern  Medicine"  was  diarrhea  present,  though 
in  every  case  presumably  the  intestines  were  extensively  ulcerated. 
The  conditions  existing  in  tuberculous  enteritis  have  already  been 
referred  to. 


DIARRHEA  1 83 

Finally,  I  would  lay  especial  emphasis  on  the  fact  obvious  from 
the  study  of  the  cases  in  this  series,  that  in  many,  perhaps  most, 
cases  of  diarrhea  the  cause  is  utterly  unknown.  No  evidence  of  in- 
fection, ulceration,  food  poisoning,  cancer,  or  other  disease  can  be 
found.  In  some  of  these  cases  we  have  evidence  that  the  patient  has 
been  subjected  to  unusual  overstrain,  such  as  may  well  have  lowered 
his  powers  of  resistance  or  up^et  the  vasomotor  tone  of  his  splanchnic 
vessels.  Thus,  loss  of  sleep  and  overwork  often  appear  to  be  causa- 
tive factors;  but  the  intermediate  steps  between  these  strains  and  the 
diarrhea  are  not  clearly  known. 

TYPES  AND  DIAGNOSIS 

Can  we  recognize  what  'part  of  the  intestine  is  afected?  Many 
text-books  describe  symptom-groups  supposed  to  characterize  diar- 
rheas originating  in  the  small  intestine  and  in  the  large  intestine, 
respectively.  I  have  not  been  able,  however,  to  identify  any  diar- 
rheas originating  in  the  small  intestine.  If  there  is  a  characteristic 
symptomatology  for  such  cases  I  have  not  been  able  to  find  it.  As 
regards  the  portion  of  the  colon  affected  by  disease  one  can  say  only 
this :  that  the  presence  of  marked  tenesmus  points  almost  certainly  to 
inflammation  of  the  rectum.  Beyond  this  we  cannot  go  with  any 
certainty. 

The  study  of  the  stools  is  of  much  importance,  especially  in  prog- 
nosis. Cases  in  which  blood  and  pus  are  frequently  present  in  the 
stools  are  almost  certainly  associated  with  ulcers  of  the  large  intes- 
tine and  run  a  much  more  chronic  course  than  those  in  which  blood 
and  pus  are  absent  from  the  stools.  The  presence  or  absence  of 
mucus  in  the  stools  seems  to  be  of  Httle  importance,  especially  when 
there  is  no  other  abnormality.  Mucus  is  not  proper  ground  for  the 
inference  that  enteritis  or  ulceration  is  present.  In  many  persons 
mucus  is  passed  from  time  to  time  without  any  disturbance  of  the 
general  health  and  without  any  known  reason  whatever. 

An  excess  of  fat,  starch,  or  protein  in  the  stools  is  much  less  often 
of  value  in  diagnosis  or  prognosis  than  the  evidences  of  ulceration  just 
referred  to.  In  the  routine  examination  of  stools  for  causes  of  diarrhea 
such  an  excess  of  food  products  is  distinctly  infrequent  and  rarely 
characterizes  a  case  for  more  than  a  short  time. 

Proctoscopy  is  of  great  importance  in  prognosis.  The  presence 
or  absence  of  ulceration  in  the  rectum  and  sigmoid  can  readily  be 
decided  by  this  method  and,  other  things  being  equal,  a  much  longer 
course  can  safely  be  predicted  in  cases  showing  ulceration  of  this 


184  DIFFERENTLA.L   DLA.GNOSIS 

kind  than  in  those  free  from  it.  Thickening  and  infiltration  of  the 
bowel  wall  may  also  be  recognized  in  this  way,  and  may  furnish  evi- 
dence of  a  long-standing,  relatively  intractable  process.  In  9  cases 
of  the  Massachusetts  General  Hospital  series  the  Amccha  histolytica 
was  recognized  in  the  stools  and  led  to  the  identification  of  amebic 
dysentery.  Such  cases,  however,  are  rare  in  Massachusetts  even  as 
importations.  In  parts  of  the  country  in  which  the  Amceha  histol- 
ytica is  common  stool  examination  may  be  of  the  greatest  importance 
as  a  means  of  identifying  diarrheas  of  this  type,  since  it  may  lead  to 
their  treatment  by  the  recently  discovered  specific,  emetin. 

Diphtheric  colitis,  or  enterocolitis,  produces  no  characteristic  symp- 
toms and  no  recognizable  abnormalities  in  the  stools.  This  was  proved 
by  the  clinical  record  of  diphtheric  cases  in  which  necropsy  was  per- 
formed at  the  Massachusetts  General  Hospital. 

''Mucous  colitis,'"  or  colica  mucosa,  is,  in  my  opinion,  not  a  colitis  at 
all,  but  a  form  of  neurosis  associated  with  constipation  and  sometimes 
with  starvation.  Of  22  cases  of  this  disease  studied  at  the  Massa- 
chusetts General  Hospital,  in  only  10  was  diarrhea  present  at  any  time 
and,  even  in  those,  constipation  was  much  more  frequent.  As  a  cause 
and  a  result  of  their  neurosis  many  of  these  patients  have  acquired  the 
disastrous  habit  of  examining  their  stools  themselves,  and  it  is  almost 
pathognomonic  of  the  disease  if  the  patient  produces  a  bottle  in  which 
curious  materials  have  been  accumulated  as  the  result  of  a  minute 
study  of  his  dejecta.  Habit  and  the  mental  attitude  are  the  essential 
factors  in  these  cases. 

Prognosis. — The  general  measure  of  effectiveness  in  the  treat- 
ment of  chronic  diarrheas  of  all  types  may  be  seen  from  the  follow- 
ing figures  drawn  from  the  records  of  the  Massachusetts  General 
Hospital :  Out  of  90  cases  of  diarrhea  lasting  over  four  weeks  previous 
to  hospital  treatment,  there  were  apparently  cured  54  ,  or  60  per 
cent.,  and  unrelieved  (including  deaths)  36,  or  40  per  cent.  We 
have  called  the  favorable  cases  "apparently  cured"  because  we  have 
not  often  been  able  to  follow  their  progress  after  discharge  from  the 
wards. 

Further  analysis  of  the  results  of  treatment  in  25  cases  of  chronic 
non-fatal  diarrhea,  averaging  about  four  years  in  duration,  shows  that 
chronicity  is  not  necessarily  of  bad  prognostic  import.  It  was  found 
quite  easy  to  check  the  process  and  even  to  cure  it  in  12  out  of  these 
25  cases  in  which  organic  ulceration  and  infiltration  of  the  bowel  were 
not  indicated  by  the  presence  of  blood  and  pus  in  the  stools  or  by  proc- 
toscopy.    Chronicity,  then,  does  not  necessarily  mean  intractabihty. 


DIARRHEA  185 

Our  fatal  cases  have  rarely  been  chronic.  They  averaged  less  than 
four  months  in  duration.  In  contrast  with  this  were  2  cases  diagnosed 
as  nervous  diarrhea  and  yielding  readily  to  suggestive  therapeutics, 
though  they  had  lasted  two  years  and  five  years,  respectively. 

Of  13  patients  with  chronic  ulcerative  colitis,  5  were  apparently 
cured,  2  were  improved,  and  6  not  improved  at  all. 

Acute  Diarrheas. — So  far  as  duration  measures  severity,  the  non- 
ulcerated  acute  cases,  lasting  five  weeks  or  less,  were  as  severe  as  the 
ulcerated  cases.  The  average  duration  of  17  ulcerated  cases  (with 
blood  and  pus  in  the  stools)  was  fourteen  days  before  treatment  began 
and  thirty-eight  days  after  treatment.  In  21  non-ulcerated  cases  the 
average  duration  was  thirteen  days  before  treatment  and  twelve  days 
after  treatment. 

The  response  to  our  therapeutic  endeavors  shows  that  the  ulcer- 
ated cases  were  far  more  intractable.  In  17  out  of  21  acute  non- 
ulcerated  cases  the  movements  ceased  promptly  after  treatment  by 
rest,  diet,  and  catharsis  only.  Three  patients  needed  also  saline  irri- 
gations, and  one,  bismuth.  Opium  and  silver  nitrate  were  never 
needed  in  this  group  of  cases. 

Of  the  1 7  ulcerated  cases,  on  the  other  hand,  only  2  yielded  to  rest, 
diet,  and  catharsis  alone.  Three  of  the  17  patients  needed  opium  also; 
5  needed  jDismuth;  7,  silver  nitrate,  and  8,  normal  saline  irrigations. 
Three  of  the  7  patients  receiving  silver  nitrate  had  saline  irrigations 
as  well. 

Case  66 

A  child,  four  years  old,  entered  the  hospital  September  9,  1908, 
with  a  diagnosis  of  "subacute  appendicitis,"  made  in  the  Out-patient 
Department  by  Dr.  Simmons.  For  nine  weeks  he  had  been  having 
diarrhea,  six  to  seven  movements  a  day.  Every  three  or  four  days  he 
has  had  an  attack  of  epigastric  pain  and  vomiting.  With  the  earlier 
attacks  the  child  was  feverish.  Weight  and  strength  have  been  failing, 
though  the  appetite  has  been  good. 

Physical  examination  showed  poor  nutrition,  good  color,  normal 
chest.  The  right  side  of  the  abdomen  showed  slight  dulness  and 
slight  rigidity.  In  the  right  iliac  fossa  a  soft,  indefinite  mass,  about 
the  size  of  a  lemon,  could  be  made  out.  It  was  only  shghtly  tender. 
The  range  of  the  temperature,  pulse,  and  respiration  are  seen  in  the 
accompanying  chart  (Fig.  65). 

Discussion. — Here  is  a  subacute  diarrhea  of  moderate  intensity, 
in  a  poorly  nourished  child,  showing  a  mass  in  the  right  iliac  region 


i86 


DIFFERENTIAL  DIAGNOSIS 


and  some  fever.     The  slow  course  of  the  disease,  the  lack  of  any  severe 
pain,  or  acute  onset  are  against  appendicitis. 

Rickets  is  often  accompanied  by  such  a  diarrhea,  but  there  are 
no  evidences  of  rachitic  changes  in  the  bones  or  muscles,  and  no  way 
of  explaining,  by  tliis  diagnosis,  the  right  iUac  mass. 


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Malignant  disease,  in  a  child  of  this  age,  rarely  involves  the  right 
iUac  region  unless  a  large  tumor  of  the  kidney  extends  unusually  far 
down.     There  is  no  evidence  of  such  a  tumor  here. 

If  the  liver  and  spleen  are  normal,  as  is  here  stated,  we  have  no 
reason  to  consider  syphilis. 

Tuberculosis  of  the  mesenteric  glands  is  common  at  this  age,  is 
apt  to  produce  a  mass  in  the  region  of  the  cecum,  and  is  often  asso- 
ciated with  diarrhea  and  fever.     One  should  look  carefully  for  evi- 


DIARRHEA  187 

dences  of  tuberculosis  elsewhere  and  for  free  fluid  in  the  peritoneum, 
but  such  evidences  are  often  absent.  A  tuberculin  test  should  be 
done. 

Outcome. — After  waiting  a  week  for  some  improvement  in  the 
child's  condition,  the  abdomen  was  opened  on  September  i6th. 
A  small  amount  of  clear  serous  fluid  escaped.  The  appendix,  cecum, 
and  the  whole  of  the  large  intestine  were  dotted  with  small  nodules, 
thought  by  the  surgeon  to  be  miliary  tuberculosis.  The  appendix  was 
removed,  but  on  microscopic  examination  found  to  be  entirely  normal. 
Its  external  surface,  however,  showed  infiltration  with  round  cells, 
in  areas  containing  cheesy  centers  and  giant-cells.  The  condition  was 
pronounced  tuberculosis  by  the  pathologist.  After  operation  the 
child  continued  to  lose  weight  and  strength,  and  on  October  6th  was 
discharged  in  poor  condition. 

Case  67 

A  girl  of  eighteen,  working  in  a  hat  factory,  entered  the  hospital 
March  25,  1907.  For  two  years  the  patient  has  had  pain  in  the  lower 
left  side  of  the  abdomen,  radiating  to  the  median  Hne,  but  never  be- 
yond it,  occasionally  upward  to  the  left  shoulder.  This  pain  has  been 
worse  for  the  last  six  months,  troubles  her  more  in  the  morning,  more 
when  she  is  constipated  and  when  she  is  on  her  feet.  It  has  no  rela- 
tion to  food  or  to  micturition  and  does  not  keep  her  awake.  She  has 
no  cough  and  no  vomiting.  She  has  had  no  previous  illness.  Her 
family  history  is  good,  except  that  her  father  has  been  ill  for  as  long 
as  she  can  remember;  why  she  does  not  know. 

Physical  examination  shows  good  nutrition  and  is  negative,  save 
that  the  abdomen  is  somewhat  tender  and  rigid  between  the  um- 
biHcus  and  the  pubes.  Temperature,  blood,  and  urine  normal. 
Stomach-tube  examination  shows  nothing  remarkable.  Guaiac  test 
in  the  stools  negative.  After  a  few  days  of  liquid  and  soft-soHd  diet, 
with  Carlsbad  salts  and  a  bitter  tonic,  she  feels  much  improved. 
Examination  of  the  abdomen  under  ether,  with  rectal  examination, 
reveals  nothing  and  she  is  discharged  "well"  on  the  ist  of  April, 
1907. 

She  continued  well  and  worked  until  the  summer  of  1908,  when  she 
had  to  give  up  on  account  of  lack  of  strength.  Although  she  has  been 
at  work  she  has  had  epigastric  pain  ever  since  leaving  the  hospital, 
her  pain  aggravated  by  food,  but  not  asssociated  with  any  lack  of 
appetite.  For  eight  weeks  she  has  been  able  to  take  nothing  but  milk. 
For  a  week  she  has  had  diarrhea  and  swelling  of  the  ankles.     There  has 


i88 


DIFFERENTIAL   DLAGNOSIS 


been  no  vomiting  at  any  time,  but  she  has  lost  steadily  in  strength 
and  weight. 

She  enters  the  hospital  for  the  second  time  November  7,  1908, 
emaciated,  but  without  any  demonstrable  physical  signs  except 
moderate  edema  of  the  feet  and  ankles.  The  blood  and  urine  are 
negative  and  there  is  no  fever  during  the  three  weeks'  stay  in  the 
hospital,  but  her  pulse  is  often  above  no  (Fig.  66).  Her  weight  at 
the  time  of  entrance  is  only  75  pounds.     Guaiac  test  is  positive  in 

the  stools,  which  contain  blood 
and  mucus.  The  first  week  she 
gains  5  pounds,  but  ascites  is 
demonstrable  on  the  18th,  and 
there  is  a  slight  edema  of  the 
skin  over  the  abdomen  and 
back.  The  guaiac  test  con- 
tinues strongly  positive  and  the 
diarrhea  cannot  be  checked. 
No  tubercle  bacilli  are  found 
in  the  stools. 

Discussion.  —  We  utterly 
failed  to  understand  the  case 
during  the  patient's  first  stay 
in  the  hospital.  She  remained 
only  a  week  because  we  could 
find  nothing  wrong  on  physical 
examination.  The  long-stand- 
ing pain  in  the  left  iliac  region 
might  have  suggested  in  an  older  person  a  diagnosis  of  cancer  of  the 
sigmoid  or  diverticulitis,  but  the  patient's  age  makes  these  prac- 
tically impossible. 

Pelvic  disease,  such  as  pus-tube,  was  considered,  but  apparently 
ruled  out  as  a  result  of  the  thorough  examination  under  ether.  Our 
diagnosis,  when  she  left  the  hospital  April  ist,  was  gastric  neurosis. 

When  she  returned,  six  months  later,  the  steady  loss  of  weight 
and  strength,  the  diarrhea,  swollen  ankles,  emaciation,  and  fever  made 
it  clear  that  we  were  dealing  with  a  chronic  infectious  disease.  The 
most  definite  localizing  sign  was  the  character  of  the  stools,  which 
showed  conclusive  evidence  of  intestinal  ulceration,  namely,  blood 
and  pus. 

Ordinarily,  I  think,  not  enough  attention  is  paid  to  the  importance 
of  pus  in  the  stools.     Many  hospital  records  never  mention  it,  yet  it  is 


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DIARRHEA  1 89 

present  in  a  great  majority  of  cases  of  intestinal  ulceration  and  is  more 
distinctive  of  that  condition  than  blood.  Given  the  evidences  of  ul- 
ceration in  the  bowel,  one  has  still  to  inquire  the  cause  of  this  ulcera- 
tion. In  temperate  climates  one  may  rule  out  amebic  dysentery  unless 
the  patient  has  previously  resided  in  a  tropical  or  subtropical  climate. 
Aside  from  this  variety  of  ulcerative  enteritis,  we  know  nothing  of  the 
causes  of  such  a  condition,  except  that  a  small  proportion  of  them  are 
due  to  tuberculosis.  The  great  majority  reveal  no  cause,  either 
•during  life  or  after  death.  It  sometimes  appears  that  diseases  which 
lower  the  patient's  power  of  resistance  make  him  liable  to  infection 
in  the  intestine,  as  well  as  elsewhere.  Perhaps  the  bacteria  ordinarily 
present  in  or  upon  the  intestinal  wall  may  attack  the  tissues  when 
long-standing  diseases,  such  as  cirrhosis,  nephritis,  diabetes,  or 
arteriosclerosis,  have  weakened  the  system.  However  this  may  be,  it 
is  certainly  true  that,  in  the  great  majority  of  cases,  ulcerative  enteri- 
tis, arising  in  temperate  climates,  shows  no  known  etiologic  agent. 

This  is  of  some  importance  because  the  diagnosis  of  tuberculous 
enteritis  is  so  often  made  wrongly  in  cases  of  long-standing  diarrhea. 
In  my  opinion  this  diagnosis  should  never  be  made  unless  there  is 
abundant  evidence  of  tuberculosis  in  the  lungs  or  peritoneum,  to  one 
of  which  intestinal  tuberculosis  is  usually  secondary.  The  demon- 
stration of  ascites  on  the  i8th  made  it  natural  to  assume  that  the  ac- 
companying enteritis  was  of  tuberculous  origin. 

Outcome. — On  the  26th  I  made  the  diagnosis  of  tuberculous  peri- 
tonitis with  tuberculous  enteritis.  On  the  29th  the  patient  died. 
Autopsy  showed  tuberculous  ulceration  of  the  small  intestine  and 
one  tuberculous  ulcer  in  the  large  intestine;  also  tuberculosis  of  the 
mesenteric  and  peritoneal  l3rmph-glands;  amyloid  degeneration  of 
the  spleen  and  kidneys;  no  tuberculosis  of  the  peritoneum;  no  ascites. 

Although  my  diagnosis  was  half-right  in  this  case,  even  this  degree 
of  success  was  largely  accidental,  for  my  diagnosis  rested  chiefly  on 
the  supposed  presence  of  free  fluid  in  the  peritoneal  cavity.  This  is  a 
mistake  not  infrequently  made  in  patients  who  have  diarrhea,  as  the 
intestines  with  their  fluid  contents  can  probably  shift  from  side  to 
.side  in  such  a  way  as  to  simulate  the  movement  of  free  fluid. 

Case  68 

A  baker  of  twenty-eight  entered  the  hospital  July  9,  1909,  for 
diarrhea.  Ten  years  ago  he  had  syphilis;  one  year  ago,  gonorrhea. 
Otherwise  he  has  been  well.  Ten  weeks  ago,  after  eating  half  a  dozen 
overripe  bananas,  he  began  to  have  abdominal  pain  and  diarrhea. 


igo  DIFFERENTIAL  DIAGNOSIS 

Five  or  sLx  watery  movements  a  day  have  continued  ever  since. 
There  is  no  blood  and  no  pain  with  movements,  but  the  taking  of  food 
excites  pain.  The  appetite  is  poor,  but  he  has  never  vomited.  He 
has  been  losing  weight  and  strength  and  thinks  he  has  had  fever  at 
times.  Three  months  ago  he  says  he  weighed  150  pounds,  with  his 
clothes.  At  entrance  he  weighed  114  pounds,  without  clothes.  He 
worked  until  three  days  ago. 

On  physical  examination  the  patient  was  well  nourished,  and 
during  a  month's  stay  showed  almost  constantly  subnormal  tem- 
perature and  pulse,  the  latter  ranging  between  50  and  60,  while  the 
temperature  averaged  97°  F.  The  physical  examination  was  wholly 
negative.  The  blood  and  urine  were  normal.  The  stools  contained 
much  undigested  food — meat,  potato,  and  corn  were  identified  with 
the  naked  eye.  Microscopic  examination  shows  an  excess  of  fat, 
soap,  and  fatty  acid;  no  mucus,  pus,  or  parasites.  Guaiac  test 
strongly  positive.  On  a  Schmidt  diet  the  amount  of  muscle  was 
somewhat  less.  There  was  still  much  free  starch  and  fat,  especially 
neutral  fat,  calcium  soaps,  and  colorless  soaps.  Guaiac  test  was  still 
markedly  positive.  Dr.  H.  F.  Hewes  saw  the  patient  July  8th,  and 
thought  there  was  either  some  involvement  of  the  pancreas  or  some 
lesions  high  up  in  the  intestinal  tract.  He  prescribed  a  diet  consist- 
ing of  meat  once  a  day,  milk  once  a  day,  four  slices  of  toast,  custard, 
jelly,  macaroni,  potato  puree,  and  white  of  egg.  On  this  diet  the 
patient's  diarrhea  ceased,  and  he  began  to  gain  in  weight  and  strength 
as  soon  as  glucose,  100  grams  a  day,  was  added  to  the  diet,  though 
there  still  continued  to  be  an  excess  of  fat  in  the  feces.  After  the 
24th  he  began  to  gain  in  weight,  and  in  the  week  following  that  date 
gained  8  pounds,  so  that  he  left  the  hospital,  July  31st,  weighing  121 
pounds.  At  that  time  Dr.  Hewes  considered  the  case  one  of  func- 
tional diarrhea,  due  to  some  disturbance  high  up  in  the  intestine,  pos- 
sibly an  interstitial  pancreatitis. 

August  6th  the  patient  re-entered  the  hospital,  stating  that  he 
had  been  unable  to  work  since  leaving  the  hospital,  as  his  diarrhea 
at  once  recurred,  three  or  more  movements  a  day.  Three  days  ago 
he  began  to  have  abdominal  pain  and  the  stools  increased  to  nine 
a  day.  He  stated  that  he  had  adhered  strictly  to  the  fat-free  diet 
given  him  when  he  left.  His  weight  August  6th  was  118  pounds. 
He  was  put  at  once  upon  the  same  fat-free  diet  and  gradually  improved. 
Nevertheless,  August  15th  there  was  still  a  great  excess  of  fatty  acids, 
crystals,  and  soaps.  He  was  then  given  a  diet  containing  nothing 
but  lean  meat,  albumin-water,  and  toast.     This  checked  his  diarrhea, 


DIARRHEA 


191 


although  microscopic  examination  of  the  formed  movements  showed, 
August  27th,  that  some  excess  of  fat  was  still  present.  In  five  weeks' 
stay  he  increased  in  weight  to  124^  pounds  and  during  the  last  three 
weeks  had  no  diarrhea. 

He  left  the  hospital  September  9th,  but  returned  December  24th, 
having  been  two  months  at  Tewksbury  Almshouse  in  the  interim. 
His  abdomen  had  been  sore,  especially  near  the  navel  and  to  the  left 
of  it,  for  two  weeks.  The  diarrhea  had  gradually  returned  and  he  said 
he  had  lost  30  pounds  in  three  months,  though  adhering  closely  to  a 
fat-free  diet.     The  examination  of  the  abdomen  now  showed  a  nodu- 


Fig.  67. — Mass  felt  in  Case  68. 

lar,  tender  mass,  as  indicated  in  Fig.  67.  During  this,  his  third  stay  in 
the  hospital,  he  had  no  diarrhea,  but  his  weight  was  only  105  pounds 
at  entrance,  increasing  a  couple  of  pounds  in  the  next  ten  days.  Jan- 
uary 2,  1 9 10,  the  tumor  was  very  much  less  distinct,  if,  indeed,  it  was 
palpable  at  all.  He  was  given  pancreon,  10  gr.  three  times  a  day  after 
meals,  but  without  effect. 

January  9th  it  was  decided  to  open  the  abdomen,  with  a  view  to 
relieving,  if  possible,  some  lesion  of  the  pancreas,  but  on  examination 
the  stomach  and  pancreas  were  found  to  be  normal.  At  the  splenic 
flexure  of  the  colon  there  was  a  solid  tumor  the  size  of  a  hen's  egg. 


192  DrFFERENTLA.L  DIAGNOSIS 

from  which  a  projection  extended  downward,  beneath  the  perito- 
neum. At  the  root  of  the  mesentery,  corresponding  to  the  jejunum, 
a  soft  mass  of  glands  was  found.  One  of  these  was  removed,  but 
showed,  on  examination  by  Dr.  W.  F.  Whitney,  a  normal  lymph- 
gland  structure  except  for  some  evidence  of  hypertrophy.  As  it  was 
thought  impossible  to  remove  the  splenic  mass,  the  abdomen  was 
therefore  closed.  The  fatty  stools  continued  after  operation.  He 
seemed  to  have  considerable  pain  and  some  tenderness  to  the  right 
of  and  above  the  navel. 

On  the  29th  of  January  both  hands  were  forcibly  flexed  at  the 
wrist,  with  all  the  fingers  likewise  flexed.  Although  the  latter  could 
be  readily  straightened  out,  they  immediately  returned  to  their 
former  position  when  let  alone.  At  this  time-  he  could  speak  only  in 
a  whisper.  The  house  officer  considered  the  attack  one  of  hysteria. 
On  the  17th  of  February  there  was  an  attack  similar  to  that  above 
described,  but  this  time  the  patient  seemed  very  much  confused  and 
semicomatose.  The  knee-jerks  were  normal.  Later  in  the  morning 
the  patient  complained  of  numbness  in  his  hands.  From  time  to 
time  thereafter  he  vomited  large  amounts  of  food  material.  He 
remained  in  the  hospital  until  February  23d,  but  did  not  gain  appre- 
ciably and  was  discharged  unrelieved. 

Discussion. — The  recurrence  of  diarrhea  in  this  case,  and  its  cessa- 
tion when  the  fats  of  the  food  were  limited,  seem  to  prove  an  intoler- 
ance of  the  patient's  system  to  fat.  We  have  no  special  reason  to 
incriminate  the  pancreas,  since  after  the  very  first  the  proteins  and 
carbohydrates  seemed  to  be  well  taken  care  of.  We  were  altogether 
in  the  dark  as  to  the  cause  of  the  fat  intolerance  until  the  mass  shown 
in  the  diagram  made  its  appearance,  and  even  after  that  was  discov- 
ered there  was  no  good  explanation  of  the  diarrhea,  since  the  intestine 
was  apparently  not  interfered  with. 

From  the  situation  of  the  mass  and  the  age  of  the  patient  a  malig- 
nant lymphoma  or  a  tuberculosis  of  the  retroperitoneal  glands  seem 
most  probable.  The  softness  of  the  gland  at  the  root  of  the  mesentery 
favors  tuberculosis,  but  the  histologic  examination  negatives  this,  at 
any  rate,  so  far  as  the  gland  examination  is  concerned. 

The  attack  of  the  29th  of  January  may  have  been  hysteria,  but 
was  more  probably  tetany. 

Outcome. — He  went  to  Tewksbury  State  Hospital  and  died  July 
21,  1910.  The  cause  of  death  was  beheved  to  be  carcinoma  of  the 
splenic  flexure.  Lymphoma  seems  to  me  more  probable.  There  is 
no  record  of  any  postmortem  examination. 


DIAREHEA  1 93 


Case  69 


The  patient,  a  housewife  of  twenty-nine,  was  first  seen  July  3, 
1907,  when  she  entered  the  hospital  for  dysmenorrhea,  nervousness, 
and  a  mass  which  she  feels  moving  in  the  abdomen.  Both  tubes  and 
ovaries  were  removed  supposedly  for  subacute  salpingitis.  She  did 
well  after  that,  but  came  to  the  hospital  again  October  8,  1908,  on 
account  of  diarrhea  which  began  in  July,  1908.  The  movements  at 
first  were  as  frequent  as  fifteen  in  an  hour  and  contained  fresh  blood. 
They  were  associated  with  pain  during  and  just  before  the  evacua- 
tion. In  July  she  also  had  epigastric  distress  after  eating,  and  soon 
after  began  to  vomit  green  and  slimy  material  in  small  amounts. 
For  the  past  eighteen  days  she  has  been  improving  and  was  now 
troubled  with  raising  large  amounts  of  gas.  Her  bowels  were  con- 
stipated and  she  had  very  Httle  gastric  distress.  She  had  been  much 
in  the  open  air,  and  her  color,  which  was  naturally  dark,  had  become 
much  darker.  During  this  sickness  she  has  lost  about  25  pounds. 
She  now  weighs  119  pounds. 

Physical  examination  showed  a  dark  skin,  especially  on  the  arms 
and  face.  The  folds  of  the  axillae  were  also  markedly  pigmented  and 
above  the  crests  of  the  ilia  the  skin  was  dark  brown  in  color.  She  was 
well  nourished  and  showed  no  pigmentation  in  the  mouth.  Physical 
examination  was  generally  negative  except  for  dulness  in  the  flanks 
of  the  abdomen,  shifting  with  change  of  position.  There  was  no  fever 
in  two  weeks'  observation.  Systolic  blood-pressure,  125  to  130. 
The  blood  and  urine  were  normal.  The  stomach  capacity  was  44 
ounces.  There  was  no  residue  before  breakfast.  Gastric  acidity 
was  not  tested.  On  the  i6th  of  October  the  ascites  seemed  to  be  in- 
creasing, though  she  seemed  in  other  respects  better.  At  times  it 
seemed  as  if  the  fluid  were  encysted,  as  it  did  not  shift  freely  with 
change  of  position.  At  other  times  a  demonstrable  shifting  seemed 
clear.  After  5  mg.  of  old  tuberculin,  subcutaneously,  there  was  no 
reaction. 

On  the  2 2d  of  October,  1908,  she  left  the  hospital.  August  16, 
1909,  she  returned,  having  been  in  fair  health  and  having  attended  to 
her  housework  meantime,  though  she  had  been  subject  to  crying 
spells,  with  nervousness  and  shivering.  In  June,  1909,  she  began  to 
have  abdominal  pain  and  diarrhea,  with  blood  and  mucus  in  the 
stools.  These  symptoms  had  continued  ever  since,  save  for  remissions 
of  a  few  days,  from  time  to  time.  She  had  had  no  formed  stools  since 
June.     Their  number  was  six  to  ten  daily  and  they  were  accom- 

VoL.  11—13 


194  DIFFERENTIAL  DIAGNOSIS 

panied  by  griping,  paroxysmal  pain,  lasting  ten  minutes  and  repeated 
every  hour  or  so.  She  had  had  practically  no  gastric  troubles.  When 
seen  August  i6,  1909,  she  was  well  nourished  and  showed  no  physical 
sign  of  disease.. 

Discussion.— Here  is  a  patient  who  has  suffered  during  two  suc- 
cessive summers  from  severe  diarrhea.  There  are  some  suggestions  of 
a  neurotic  temperament.  Addison's  disease  is  suggested  by  the  dark- 
brown  pigmentation  of  the  skin,  as  well  as  by  the  loss  of  weight  and 
vomiting.  There  was  no  record  of  low  blood-pressure  and  no  cardiac 
symptoms;  the  remissions  which  have  characterized  the  disease  are 
very  unlike  the  progressive  course  of  Addison's  disease,  also  her  good 
condition  in  August,  1909. 

The  apparent  presence  of  fluid  in  the  abdomen  and  the  pigmenta- 
tion, as  well  as  the  diarrhea,  are  common  in  tuberculous  peritonitis, 
but  against  this  are  the  negative  tuberculin  reaction,  the  absence  of 
temperature,  and  the  lack  of  any  spasm  or  pain,  even  slight,  in  the 
abdominal  muscles. 

The  diagnosis  made  and  thus  far  unrefuted  was  of  a  diarrhea  de- 
pendent upon  the  patient's  nervous  and  mental  condition.  There 
were  many  indications  that  if  a  Social  Service  worker  had  gained  her 
confidence  and  looked  into  her  home  conditions,  her  worries  and  asso- 
ciations, some  more  definite  cause  might  have  been  found  in  her  tem- 
perament or  environment. 

Outcome. — There  was  no  fever  in  four  weeks'  observation,  during 
which  time  she  gained  8  pounds  in  weight,  which  was  at  the  end  119 
pounds.  On  a  Schmidt  diet  she  had  no  diarrhea,  normal  stools,  and 
within  a  short  time  was  given  house  diet,  which  was  also  well  borne. 
Though  very  nervous,  she  improved  markedly,  and  went  home  on  the 
8th  of  September.  She  was  seen  again  December,  1910,  when  she 
had  an  incomplete  miscarriage  (?),  but  no  more  trouble  with  her 
bowels.  January,  191 2,  she  had  continued  well.  Obviously,  there 
must  have  been  some  mistake  in  the  report  that  both  tubes  and 
ovaries  were  removed  in  1907. 

Case  70 

A  janitor  of  thirty-four,  born  in  Russia,  entered  the  hospital 
November  22,  1909.  His  family  history  and  past  history  were  not 
remarkable,  and  he  had  been  perfectly  well  until  last  May,  when, 
after  working  hard  and  getting  very  hot,  he  drank  some  ice-water. 
This  was  followed  by  a  pain  in  the  epigastrium  and  right  hypochon- 
drium,  and  within  a  few  hours  by  a  bad  diarrhea  with  some  blood  in 


DIAREHEA 


195 


the  stools.  At  first  he  had  four  or  five  movements  an  hour,  and  since 
then  he  has  been  unable  to  work  on  account  of  diarrhea.  Excessive 
frequency  of  micturition  accompanied  his  other  troubles.  At  first 
there  was  blood  in  his  urine,  but  this  was  not  seen  again  until  this 
morning,  when  he  passed  small  amounts  of  blood  frequently.  Of  late 
he  must  pass  his  urine  at  least  twenty  times  in  the  night.  There  has 
been  pain  low  down  in  the  abdomen  for  four  months  and  a  half. 

His  appetite  has  remained  good  and  he  has  had  no  vomiting,  but 
meat  causes  distress. 


hull   Sl^^ 

tcYiSeT. 


Fig.  70. — Position  of  "mass"  and  tenderness  in  Case  70. 


Physical  examination  was  negative  except  as  relates  to  the  ab- 
domen, where  "a  hard  slightly  irregular  mass,  dull  on  percussion  and 
tender,"  was  found  in  the  position  shown  in  Fig.  70.  There  was  no 
evidence  of  fluid  in  the  belly.  Rectal  examination  showed  a  large 
hard  mass  in  the  region  of  the  prostate,  not  tender,  but  apparently 
connected  with  the  suprapubic  mass.  After  catheterization  the  latter 
disappeared  and  was  evidently  due  to  a  distended  bladder.  The 
urine,  at  the  time  of  entrance,  contained  almost  nothing  but  blood 
and  was  1030  in  specific  gravity.  Leukocytes,  9700.  Hemoglobin, 
90  per  cent.     Weight,  133  pounds.     Temperature  as  in  the  accom- 


196 


DIFFERENTLA.L  DIAGNOSIS 


panying  chart  (Fig.  71).  The  patient  refused  operation.  The  blad- 
der was  washed  free  of  blood-clots,  and  thereafter  he  was  able  to  pass 
a  fair  amount  of  bloody  urine.  December  ist  gonococci  were  found 
in  his  urethral  discharge.  He  continued  to  complain  of  pain  on  mic- 
turition and  would  drink  but  Httle  water.  The  urine  contained  so 
much  blood  that  nothing  else  could  be  distinguished  in  it.  Its  amount 
averaged  40  ounces  in  twenty-four  hours.  He  seemed  to  be  in  pretty 
fair  condition  until  the  afternoon  of  the  24th  of  December,  when  he 

complained  of  pain  and  slept  so  poorly 
that  he  was  given  J  gr.  of  morphin,  sub- 
cutaneously. 

Discussion. — The  association  of  diar- 
rhea with  hematuria  is  common  in  cancer 
of  the  bowel  extending  to  the  bladder; 
also  in  neoplasms  of  the  bladder  and 
prostate,  involving  the  bowel.  In  the 
tropics,  bilharziasis  is  also  a  common 
cause  of  proctitis  and  hemorrhagic  cys- 
titis, but,  so  far  as  is  known,  this  patient 
has  never  Uved  in  a  country  where  such 
infections  are  common.  Since  rectal  ex- 
amination shows  no  evidence  of  rectal 
cancer,  it  seems  more  reasonable  to  be- 
Heve  that  the  trouble  originated  in  the 
bladder  or  prostate. 

Gonorrhea  can  affect  both  bladder  and 
rectum,  but  never  produces  so  profuse  a 
discharge  of  blood.  The  presence  of  gonococci  in  the  urethral  dis- 
charge had  nothing  to  do  with  his  main  disease. 

The  excessive  and  continued  hematuria  are  not  consistent  with 
any  known  disease  of  the  kidney.  Hematuria  from  this  source  is  not 
often  associated  with  such  dysuria  and  frequency. 

Malignant  disease  of  the  bladder  is  not  common  at  thirty-four,  but, 
taking  all  things  into  consideration,  no  better  diagnosis  can  be  made. 
The  drinking  of  ice-water  was  probably  of  no  importance  in  the  case. 
Outcome. — Two  and  a  half  hours  after  the  morphin  injection  of 
December  24th  he  was  found  to  be  pulseless,  and  on  the  arrival  of  the 
house  officer  was  dead.  Autopsy  (No.  2492)  showed:  Squamous-cell 
carcinoma  of  bladder  with  bone  formation  in  the  stroma;  occlusion 
of  ureters  in  bladder  wall;  suppurative  nephritis  of  right  kidney; 
atrophy  of  right  kidney  with  dilatation  of  its  pelvis;  compensatory 


Nov.                             ■3)ec 

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Fig.  71. — Chart  of  Case  70. 


DIARRHEA 


197 


hypertrophy  of  left  kidney;  dilatation  of  ureters;  obsolete  tuberculosis 
of  the  mesenteric  lymph-glands;  chronic  pleuritis.  The  intestine  was 
not  remarkable. 

Case  71 

A  salesman  of  twenty-four  entered  the  hospital  January  27,  19 10, 
with  a  diagnosis  of  ''tubercular  enteritis"  (Out-patient  Department, 
142,612).  Family  history  negative.  The  patient  had  typhoid  fever 
eight  years  ago  and  no  other  illness  of  importance.  He  smokes  one 
or  two  boxes  of  cigarettes  a  day. 

January  3d  he  had  severe  pain  in  the  right  lower  quadrant  and  a 
temperature  of  102°  F.  Also  some  pain  in  the  left  upper  quadrant. 
He  went  to  bed  for  five  days, 
and  since  he  got  up,  nineteen 
days  ago,  he  has  had  an  ob- 
stinate diarrhea,  sometimes 
twenty-four  movements  a  day, 
with  much  colorless  mucus. 
He  has  now  no  pain  in  the 
right  lower  quadrant,  but  a 
week  ago  he  was  so  sore  along 
that  side  of  his  abdomen  that 
he  could  hardly  move  his  right 
leg,  and  he  has  therefore  re- 
mained in  bed  since  that  time. 
There  has  been  no  nausea  or 
vomiting  since  the  3d  of  Janu- 
ary, but  he  believes  that  he 
has  had  a  little  fever  for  at 
least  forty-eight  hours.  His 
appetite  for  the  past  ten  days 
has  been  poor,  and  his  sleep  poor  for  three  weeks 
ginning  of  his  illness  he  has  lost  13  pounds. 

Temperature  at  entrance,  99.2;  pulse,  102;  respiration,  25.  White 
cells,  27,000,  the  stained  smear  showing  polynuclear  leukocytosis. 
Urine  negative.  Chest  negative.  Abdomen  tympanitic,  the  upper 
portion  gradually  becoming  dull  as  one  approached  the  pubes.  In  the 
right  lower  quadrant  an  indistinct  mass,  the  size  of  an  egg,  was  felt, 
and  there  was  some  spasm  and  tenderness  in  this  region.  "Rectal 
examination  reveals  a  hard  prostate,  either  enlarged  or  pushed  down. 
The  large  mass  felt  seems  like  a  full  bladder."     The  course  of  the 


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Fig.  72. — Chart  of  Case  71. 

Since  the  be- 


198  DIFFERENTIAL  DIAGNOSIS 

temperature  during  the  patient's  three  weeks  in  the  medical  wards 
was  as  seen  in  the  accompanying  chart  (Fig.  72). 

Discussion. — The  age  of  the  patient,  together  with  the  diar- 
rhea, the  soreness,  and  the  mass  in  the  cecal  region,  are  quite  consist- 
ent with  an  abdominal  tuberculosis.  The  duration  of  the  symptoms 
also  favors  this.  Against  it,  however,  are  the  high  leukocyte  count 
and  the  absence  of  any  considerable  fever  during  most  of  his  three 
weeks  in  the  ward. 

The  only  type  of  neoplasm  often  seen  in  persons  so  young  is 
malignant  lymphoma,  and  this  is  seldom  associated  with  so  marked  a 
leukocytosis  or  so  obstinate  a  diarrhea.  In  the  majority  of  cases, 
moreover,  malignant  lymphoma  is  multiple. 

Appendicitis  would  account  for  the  mass  and  the  leukocytosis, 
but  against  appendicitis  are  the  prolonged  diarrhea  and  the  absence 
of  any  marked  elevation  in  temperature  or  pulse.  The  cUnical  diag- 
nosis favored  abdominal  tuberculosis. 

Outcome. — On  the  29th  of  January  the  abdomen  was  opened, 
the  small  intestine  found  matted  together  about  the  cecum.  A  small 
cavity  of  pus,  containing  about  2  drams,  was  found  at  one  side  of  the 
cecum.  The  appendix  was  found  adherent  to  the  cecum  and  perfor- 
ated at  the  tip.  No  evidence  of  perforation  was  found  in  the  gut. 
The  patient  did  well  after  operation  and  was  discharged  February 
i6th.  Examined  February  18,  191 1,  he  seemed  to  be  entirely  well. 
Why  the  patient  never  had  any  elevation  of  temperature  and  pulse, 
and  why  he  had  so  much  diarrhea,  I  do  not  know. 

Case  72 

A  schoolboy  of  eighteen,  born  in  Turkey,  enters  the  hospital 
April  19,  1910.  He  has  been  in  this  country  only  eight  months,  but 
has  been  sick  for  considerably  more  than  a  year  with  obstinate  diar- 
rhea in  recurrent  attacks  and  with  almost  constant  abdominal  pain. 
Owing  to  his  scanty  acquaintance  with  English,  no  further  history  is 
obtained. 

The  patient  is  emaciated  and  has  a  dry,  harsh  skin.  His  eyelashes 
are  noticeably  long.  Fingers  slightly  clubbed  at  the  ends.  His  chest 
negative.  Abdomen  slightly  distended,  tympanitic  in  the  epigastrium, 
dull  in  the  flanks,  the  dulness  shifting  with  change  of  position.  The 
whole  right  side  is  slightly  spastic,  especially  in  the  right  lower  quad- 
rant. Visceral  examination  otherwise  negative.  Urine  negative. 
White  cells,  6000  to  8000.  The  stained  smear  shows  moderate  achro- 
mia and  slight  deformities  of   the  red  cells.     Marked  increase  of 


DIARRHEA 


199 


blood-plates.  The  bowels  moved  three  to  ten  times  a  day  during 
his  month's  stay  in  the  hospital.  Feces  contain  much  mucus  and  an 
occasional  leukocyte.  No  excess  of  fat,  muscle,  or  carbohydrate. 
Guaiac  test  always  negative  and  no  tubercle  bacilli  or  other  organisms 
of  importance.  The  temperature  as  in  the  accompanying  chart 
(Fig.  73).  Weight,  72^  pounds,  gradually  decreasing  to  68  pounds 
during  the  course  of  his  stay.  The  camphor,  opium,  and  tannin  pill, 
large  doses  of  bismuth,  lactic  acid  milk,  the  fluidextract  of  coto  bark, 
tincture  of  catechu,  the  Schmidt  diet,  and  various  other  modihca- 


Abr,  I                                                    MOLV 
"K,,!'    1?  a*  !,|  1113  it  W  li  n  If  1"]  3t,  /    i  3   y  i- 

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tions  of  diet  were  given  without  result.  When  the  boy  left  the  hos- 
pital, May  20th,  he  was  worse  than  at  entrance. 

Discussion. — In  many  ways  this  case  resembles  the  last  (Case 
No.  71),  although  there  was  only  spasm,  no  mass  in  the  right  iliac 
region.  A  year's  diarrhea  in  a  Turk,  with  fever  reaching  repeatedly 
above  102°  F.,  and  free  fluid  (apparently)  in  the  peritoneum,  suggests 
abdommal  tuberculosis,  especially  as  the  diarrhea  proved  intractable. 

It  is  conceivable  that  in  this  case,  as  in  the  last,  appendicitis  may 
have  been  present,  but  the  low  white  count  and  the  long  course  of  the 
case  are  against  this.  Unfortunately,  we  have  no  definite  knowledge 
of  the  outcome. 


200 


DIFFERENTIAL   DIAGNOSIS 


Case  73 

A  girl  baby,  seventeen  months  old,  entered  the  hospital  June  13, 
1 9 10.  Its  parents  and  the  rest  of  the  family  are  healthy.  The 
baby  was  breast  fed  for  eleven  months  and  has  always  been  well 
until  yesterday,  when  it  ate  a  large  amount  of  fresh  bread,  potatoes, 
and  macaroni.  At  2  a.  m.  today  the  baby  waked,  feverish  and  vomit- 
ing. After  castor  oil  it  slept,  but  awakened  at  5  a.  m.  and  had  general 
convulsions  with  cyanosis  and  dyspnea.  More  castor  oil  was  given, 
but  at  8  o'clock  there  was  another  convulsion,  lasting  three  minutes. 
The  bowels  moved  five  times  normally  yesterday,  once  this  morning 
after  2  o'clock  and  again  after  an  enema. 

The  baby  is  fat  and  healthy  looking.  Tonsils  much  enlarged  and 
reddened.     Anterior  surface  of  the  pillars  is  covered  with  small  red 

papules.  Physical  examination 
otherwise  negative.  The  strep- 
tococcus is  the  predominating 
organism  in  the  throat.  The 
blood  shows  15,500  leukocytes, 
with  a  slight  polynuclear  leuko- 
cytosis. Urine  normal.  Nu- 
merous loose  stools  continued 
during  the  first  ten  days  of  the 
child's  stay  in  the  hospital,  the 
stools  containing  blood  and  pus. 
There  are  numerous  rales  scat- 
tered in  various  parts  of  the 
chest.  The  ears  are  examined, 
June  1 8th,  by  Dr.  Mosher,  who 
finds  both  ear-drums  reddened, 
and  on  puncture  recovers  a  Uttle 
pus  from  each.  By  the  25th 
the  bowel  movements  are  fewer 
in  number,  the  lungs  clearer,  and  the  ears  discharging  less.  By  the 
29th  the  stools  are  normal  in  frequency  and  quality.  This  evening 
the  pulse  is  very  slow  and  a  little  irregular.  Temperature  abnormally 
low,  but  nothing  of  importance  results  from  this  state  of  things. 

Discussion. — So  high  a  fever  in  a  young  child  should  make  us 
search  for  all  the  commoner  sites  of  infection,  and  exclude  otitis 
by  examination  of  the  ears;  bronchopneumonia,  by  examination 
of  the  chest;  and  pyelitis,  by  examination  of  the  urine. 


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DIARRHEA  20I 

Evidently  the  child  had  a  streptococcus  throat,  and  the  small  red 
papules  in  the  pharynx  made  us  look  carefully  for  an  exanthem. 
None  such,  however,  appeared,  and  when  all  the  infections  mentioned 
in  the  previous  paragraph  had  been  ruled  out,  there  remained  no 
serious  doubt  that  the  infection  was  of  intestinal  origin.  That  it  was 
not  a  mere  food  diarrhea  was  shown  by  the  presence  of  blood  and  pus 
in  the  stools,  as  well  as  by  the  duration  and  obstinacy  of  the  symptoms. 

Intussusception  would  produce  diarrhea  more  or  less  similar  to 
this,  but  would  be  unlikely  to  last  so  long  without  producing  any 
tumor,  abdominal  distention,  or  other  severe  symptoms. 

Since  no  cultures  were  made  from  the  stools,  there  is  nothing  more 
to  be  said  regarding  the  organism  at  work  there. 

Outcome. — By  the  2d  of  July  the  baby  seemed  quite  normal, 
except  for  a  slight  discharge  from  the  right  ear.  The  treatment  con- 
sisted of  milk  feedings,  3  ounces  every  three  hours,  alcohol  sponges  at 
80°  F.  for  fever,  and  rectal  irrigations  every  six  hours  with  a  quart  of 
warm  salt  solution.  The  ears  were  syringed  every  two  to  four  hours 
with  warm  boric  acid  solution.  Water  was  offered  the  child  very 
frequently.  The  course  of  the  disease  is  well  indicated  in  the  ac- 
companying temperature  chart  (Fig.  74). 

Case  74 

A  widow  of  sixty-four  entered  the  hospital  June  21,  19 10.  Family 
history  and  past  history  uneventful.  In  August,  1909,  she  began  to 
have  diarrhea,  with  five  or  six  loose  movements  a  day,  each  preceded 
by  cramps  in  the  left  lower  abdomen,  radiating  from  the  region  of 
the  hip  down  the  leg,  and  relieved  by  the  passage  of  feces.  She 
has  had  no  normal  movements  since  August,  1909.  In  February, 
1910,  she  began  to  notice  blood-streaked,  jelly-like  masses  in  the 
movements,  and  since  that  time  she  has  been  confined  to  bed  for  a  day 
or  two,  off  and  on,  in  order  to  relieve  the  pain.  For  four  weeks  her 
bowels  have  been  costive  at  times.  Since  February,  19 10,  the  ab- 
domen has  been  greatly  swollen,  the  swelling  more  or  less  relieved  in 
the  last  two  months  by  four  spoonfuls  of  castor  oil  each  morning. 
The  appetite  has  been  fair  until  about  a  month  ago,  at  which  time 
she  had  to  give  up  work.  Her  usual  weight,  180  pounds;  now,  151 
pounds. 

On  physical  examination  the  patient  is  still  fat,  but  sallow  and 
pale.  The  head  and  chest  are  negative.  The  abdomen  shows  in 
the  left  iliac  fossa  an  indefinite,  very  tender  mass,  about  the  size  of  an 
orange,  but  is  otherwise  negative. 


202  DIFFERENTIAL  DIAGNOSIS 

Discussion. — Malignant  disease  of  the  sigmoid  is  certainly  the 
diagnosis  which  comes  first  to  our  minds,  but  we  are  less  confident 
of  this  impression's  correctness  when  we  note  that  the  patient  con- 
tinued her  work  until  a  month  ago  and  that  she  is  still  fat,  despite 
the  loss  of  nearly  30  pounds.  Nevertheless,  it  is  well  known  that 
intestinal  neoplasms  have  a  remarkable  latency  and  mildness  in 
many  cases. 

Diverticulitis  is  a  possibility  which  must  always  be  taken  into 
consideration  when  cancer  of  the  sigmoid  is  our  first  choice,  since 
the  cases  pubHshed  within  the  past  five  years  make  it  clear  that  these 
two  diseases  may  be  almost  or  quite  indistinguishable  without  his- 
tologic examination  of  the  tumor  mass. 

In  this  case  the  absence  of  fever  and  leukocytosis  and  the  notable 
discharge  of  blood  incline  us  to  favor  cancer. 

Tuberculosis  rarely  appears  in  the  abdomen  at  this  age,  and  rarely 
shows  itself  in  the  region  of  the  sigmoid.  The  cecum  and  the  epi- 
gastric region  are  its  commonest  sites  of  manifestation. 

Outcome. — June  27th  the  abdomen  was  opened  and  a  cancerous 
mass  found  in  the  sigmoid,  involving  the  entire  gut  for  4  or  5  inches, 
the  mass  itself  being  about  the  thickness  of  a  man's  wrist,  hard  and 
nodular.  Glandular  infiltration  was  extensive  in  the  neighborhood.  A 
right  inguinal  colostomy  was  done.  The  patient  made  a  good  recov- 
ery from  the  operation  and  was  discharged  in  good  condition  on 
July  19th. 

Case  75 

A  shirtwaist  maker  of  twenty-two,  unmarried,  entered  the  hospital 
August  16,  1 9 10,  with  a  diagnosis  of  typhoid  fever.  Thirteen  days 
previously  she  began  to  have  diarrhea,  four  or  five  movements  daily, 
continuing  until  three  days  ago,  since  when  she  has  been  constipated. 
Nine  days  ago  she  left  work  and  went  to  bed  on  account  of  weakness. 
She  has  felt  feverish  and  chilly,  and  during  the  last  two  or  three  days 
has  had  severe  headache. 

Physical  examination  showed  good  nutrition,  normal  chest  and 
abdomen.  Normal  extremities.  White  cells,  7000,  with  55  per  cent, 
of  polynuclear  cells.  Urine  negative.  The  Widal  reaction  was  done 
every  second  day  for  two  weeks,  and  every  four  days  thereafter,  until 
the  20th  of  September.  At  no  time  was  there  any  evidence  of  a  posi- 
tive reaction.  She  had  no  diarrhea  during  her  stay  in  the  hospital. 
Temperature  was  as  in  the  accompanying  chart  (Fig.  75).  She 
looked  typically  typhoidal.     At  one  time  in  the  early  days  of  Sep- 


DIAREHEA 


203 


tember  she  had  considerable  pain  on  micturition,  but  this  pain  ceased 
when  the  urotropin  was  omitted,  a  drug  which  had  previously  been 
given  in  doses  of  5  gr.  every  four  hours.  The  agglutinative  reaction 
with  the  alpha-  and  beta-paratyphoid  were  negative,  but  with  the 
Bacillus  coli  a  positive  reaction  was  obtained  in  a  dilution  of  i  to  40. 
Discussion. — A  short  fever,  preceded  by  ten  days'  diarrhea  and 
ending  in  recovery,  presents  itself  in  this  case.  Arguing  from  the 
agglutinative  reaction  with  the  colon  bacillus,  one  is  inclined  to  class 
this  as  a  colon  bacillus  infection,  but  it  is  to  be  remembered  that  the 
number  of  demonstrated  cases  of  generalized  infection  from  colon 


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bacilli  is  very  small,  and  that  many  strains  of  colon  bacilli  are  ag- 
glutinated in  considerable  dilution  by  normal  blood-serum. 

But  for  the  absence  of  the  Widal  reaction  the  case  would  un- 
doubtedly be  classed  as  one  of  abortive  typhoid,  and  I  do  not  see 
that  this  disease  can  be  excluded.  It  is  not  reasonable  to  hang  our 
diagnosis  or  our  refusal  of  diagnosis  wholly  upon  a  single  laboratory 
finding,  such  as  a  Widal  reaction.  The  presence  of  diarrhea  is,  if 
anything,  rather  against  typhoid,  as  it  occurs  in  only  20  per  cent,  of 
cases. 

Typhus  fever  (Brill's  disease)  was  not  considered  in  this  case,  yet 
it  seems  to  me  to  deserve  consideration  because  of  the  duration  of  the 


204 


DIFFERENTIAL   DLA.GNOSIS 


case  and  the  tolerably  rapid  lysis.  Against  typhus  is  the  normal 
white  count  (it  should  be  ii,ooo  to  13,000)  and  the  absence  of  any 
cutaneous  eruption.  Nevertheless,  I  do  not  think  that  this  diagnosis 
can  be  excluded, 

I  see  no  reason  to  consider  seriously  the  phrases  "grip"  or  "fe- 
bricula,"  terms  often  applied  to  short  fevers  of  unknown  origin,  but 
undesirable  because  they  give  the  appearance  of  knowledge  without 
the  reality. 

Outcome. — Blood  culture  was  negative.  September  20th  she  had 
gained  7  pounds,  was  walking  without  fatigue,  and  was  allowed  to  go 
home. 

Case  76 

A  sewing  girl  of  twenty  entered  the  hospital  September  15,  19 10. 
The  patient's  mother  died  at  forty-two  of  gastric  cancer.  All  her 
family  are  nervous.  In  April,  1908,  she  was  operated  upon  in  St. 
Joseph's  Hospital,  Providence,  for  a  cervical  swelling  of  four  months' 
duration.  Otherwise  she  was  well  until  her  present  illness,  but  she  has 
been  in  the  habit,  during  the  last  three  or  four  months,  of  drinking 
19  to  20  cups  of  fairly  strong  tea  a  day.  Before  this  time  she  took 
only  about  3  cups  of  tea  a  day. 

In  March,  1909,  without  known  cause  and  without  previous 
stomach  symptoms,  she  was  suddenly  seized  with  severe  epigastric 
pain,  relieved  only  by  morphin,  In  the  course  of  three  days  this 
pain  wore  off  and  she  went  back  to  work,  but  never  since  that  time 
has  she  been  free  from  epigastric  pain  and  hardly  a  day  has  passed 
without  vomiting.  During  July,  August,  September,  October,  and 
November,  1909,  she  was  in  St.  Joseph's  Hospital  at  Providence. 
In  November  she  was  operated  upon  by  Dr.  Harris,  and  in  January, 
1 9 10,  she  went  to  work  again,  but  in  March  began  to  have  pain  in  the 
right  iliac  fossa,  which  led  to  a  second  operation  at  the  same  hospital 
by  Dr.  McKenna,  April  ist.  For  the  past  two  months  she  has  had 
an  attack  of  pain  in  the  left  iliac  fossa  every  few  days,  lasting  fifteen 
to  twenty  minutes,  and  sometimes  extending  down  the  front  of  the 
thigh. 

Meantime  the  stomach  symptoms  have  continued  without  much 
variation.  Knife-like  epigastric  pain  comes  immediately  after  eat- 
ing, and,  if  not  relieved  by  vomiting,  lasts  fifteen  or  twenty  minutes. 
After  that  it  becomes  moderate  and  constant.  Her  pain  is  not  re- 
lieved by  soda,  by  food  or  drink,  and  does  not  radiate,  but  is  much 
relieved  by  vomiting,  which  occurs  after  almost  every  meal,  is  never 


DIARRHEA  205 

large  in  amount,  and  never  contains  blood  or  food  eaten  the  day 
before. 

Throughout  the  illness  her  appetite  and  sleep  have  been  good. 
Bowels  usually  regular.  She  has  not  worked  for  six  months.  Two 
years  ago  her  weight  was  143  pounds;  December  i6th  her  weight, 
without  clothes,  was  found  to  be  ioo|  pounds. 

Despite  this  apparent  loss  of  weight,  she  was  well  nourished  and 
had  a  good  color.  Her  hands  and  feet  were  always  cold  and  clammy. 
On  the  right  side  of  the  neck,  below  and  behind  the  ear,  was  an  opera- 
tion scar,  I  inch  long.  There  were  no  enlarged  lymph-glands  present 
anywhere.  Chest  negative.  The  abdomen  was  tympanitic  in  the 
lower  part,  dull  above,  with  shght  involuntary  resistance  in  the  right 
upper  quadrant  and  epigastrium.  A  9  cm.  vertical  scar  was  seen 
above  the  umbihcus,  to  the  left  of  the  median  line.  Another,  8  cm. 
long,  in  the  right  lower  quadrant. 

The  blood  was  negative;  likewise  the  urine  when  obtained  by 
catheter,  though  the  routine  specimen  obtained  without  special 
precautions  showed  a  pus  sediment  of  about  5  per  cent,  of  the  total 
amount  of  urine  when  centrifugalized  five  minutes  at  the  rate  of  one 
thousand  revolutions  per  minute.  Her  vomitus  contained  free  HCl 
and  reacted  strongly  to  guaiac.  It  contained  no  food  residue  or  any- 
thing else  of  interest. 

At  first  the  patient  could  retain  no  food  and  was  given  only  salt 
solution  by  rectum,  200  c.c.  every  six  hours.  By  the  third  day  she  was 
able  to  take  crackers  and  toast  with  butter,  but  the  rectal  salt  solu- 
tion was  kept  up  until  the  27th.  She  kept  down  her  crackers  and  toast, 
but  vomited  Uquids  and  cornmeal  mush.  Meantime  a  letter  was  sent 
to  St.  Joseph's  Hospital,  and  an  answer  received,  stating  that  a  gastro- 
enterostomy had  been  done,  but  making  no  mention  of  the  pathologic 
condition  found.  By  October  3d  the  patient  had  advanced  to  the 
third  stage  of  gastric  ulcer  diet  (see  Vol.  I.  of  this  work.  Appendix) 
and  was  perfectly  comfortable.  Thereafter  she  gained  steadily,  and 
had  less  epigastric  soreness. 

She  went  home  October  23d,  having  gained  13  pounds  in  weight, 
but  returned  November  19th,  stating  that  since  her  discharge  she 
had  been  very  miserable,  vomiting  almost  everything  eaten.  Bowels 
very  constipated,  her  condition  altogether  preventing  work.  She 
had  got  back  to  102  pounds  in  weight.  This  time,  despite  treatment 
similar  to  that  previously  given,  she  continued  to  vomit  occasionally, 
although  she  gained  6  pounds  during  her  first  week's  stay  in  the 
hospital. 


2o6  DIFFERENTIAL  DIAGNOSIS 

Discussion. — On  a  first  reading  of  this  case  it  is  obvious  that  she 
has  too  many  pains  in  too  many  places  to  fit  any  known  localizable 
disease,  and  of  the  generalized  diseases,  such  as  infection  or  carcinoma- 
tosis, we  have  no  evidence,  especially  as  the  appetite  and  sleep  are 
good  and  there  is  no  falling  off  in  nutrition  or  color.  Despite  the 
absence  of  hydrochloric  acid  from  the  gastric  contents,  there  is  no 
good  clinical  evidence  of  cancer  or  of  any  other  organic  disease  of  the 
stomach. 

Tabes  dorsalis  might  account  for  her  pain,  and,  although  this  is 
an  unusual  disease  in  a  girl  of  twenty,  I  do  not  see  that  it  can  be 
absolutely  excluded  in  this  case,  since  no  spinal  puncture  was  made. 
I  am  thoroughly  convinced  that  there  are  cases  of  tabes  presenting 
no  symptoms  excepting  abdominal  pain  and  a  characteristic  spinal 
fluid,  that  is,  cases  in  which  the  pupils  and  reflexes  are  normal.  In 
the  latter  part  of  her  history  pain  is  much  less  prominent,  and  the 
possibility  of  tabes  becomes  correspondingly  less. 

At  one  time  we  were  strongly  inclined  to  consider  that  some  form 
of  tuberculosis  was  at  the  bottom  of  her  troubles.  This  was  sug- 
gested by  the  scars  in  the  neck,  the  loss  of  weight,  and  the  supposed 
presence  of  pyuria.  When  the  pyuria  was  disproved,  there  seemed  no 
sufficient  ground  for  considering  this  hypothesis  any  longer. 

There  seemed  to  be  nothing  left  but  to  suppose  that  the  case  was 
one  of  functional  or  neurotic  stomach  trouble,  greatly  aggravated  by 
hospitalization  and  by  unnecessary  surgery. 

Outcome. — On  the  8th  of  December  she  was  operated  upon  by 
Dr.  Codman.  The  old  gastro-enterostomy  was  closed,  so  as  to  restore 
so  far  as  possible  a  natural  condition  of  the  stomach.  No  evidence  of 
gastric  or  duodenal  disease  was  found.  The  old  gastro-enterostomy 
was  in  excellent  condition  and  working  as  well  as  could  be  expected. 
Slight  adhesions  between  the  pylorus  and  the  gall-bladder  and  between 
the  old  scar  in  the  abdominal  wall  and  the  anterior  wall  of  the  stomach 
were  separated.  After  operation  the  patient  did  fairly  well,  but  was 
troubled  very  much  by  toothache.  She  was  entirely  relieved  of  her 
vomiting  and  was  able  to  eat  almost  every  sort  of  food.  She  left  the 
hospital  January  i6th. 

Case  77 

An  Italian  caterer  of  fifty-six  entered  the  hospital  September  i8, 
1 910.  Six  of  his  cousins  and  one  sister  died  of  tuberculosis.  His 
wife  has  had  tuberculosis  for  seven  years.  He  has  three  healthy 
children  and  his  family  history  is  otherwise  good.     At  thirteen  he  had 


DIARRHEA 


207 


pleurisy,  but  was  not  tapped.  Up  to  four  and  one-half  years  ago  he 
worked  as  a  courier,  conducting  parties  on  the  West  African  Coast,  in 
the  West  Indies,  and  in  various  parts  of  Europe.  On  these  travels 
and  occasionally  since  he  has  had  attacks  of  diarrhea,  lasting  two  or 
three  days,  and  in  winter  has  had  frequent  shght  attacks  of  bronchitis. 
Three  and  one-half  years  ago  he  had  a  severe  cough,  lasting  two 
months.  Dr.  J.  Payson  Clark  has  amputated  his  uvula  and  removed 
several  polypi  and  turbinates.  He  denies  venereal  disease.  He  takes 
2  or  3  glasses  of  wine  and  about  3  ounces  of 
whisky  a  day. 

Six  weeks  ago  he  had  an  accident,  diagnosed 
by  a  skilful  physician  as  ''rupture  of  the  plan- 
taris."  During  the  succeeding  weeks  of  en- 
forced idleness'  he  lost  his  appetite  completely 
and  ate  nothing  but  bread  and  milk.  On  the 
seventh  day,  at  2.30  p.  m.,  his  abdomen  be- 
came distended  and  painful.  Nausea,  vomit- 
ing, and  diarrhea  followed,  movements  occur- 
ring forty  to  fifty  times  a  day  for  twelve  days, 
according  to  his  statement.  After  that  he  got 
better  and  went  to  work,  though  his  bowels 
continued  to  move  eight  or  ten  times  a  day. 
He  blamed  an  overripe  peach,  eaten  yester- 
day, for  a  return  of  vomiting,  cramps,  and 
diarrhea.  Yesterday,  he  said,  his  bowels  moved 
fifty  times.  Six  weeks  ago  his  weight  was  170 
pounds;  at  entrance  his  weight,  without  clothes, 
was  150  pounds. 

He  was  well  nourished.  The  heart's  apex  extended  2I  cm.  out- 
side the  nipple  line.  The  aortic  second  sound  had  a  metallic  and 
ringing  quality.  The  systolic  blood-pressure  was  from  160  to  170 
mm.  Hg.  The  heart  showed  no  murmurs  and  no  other  abnormality. 
Physical  examination,  including  the  blood  and  urine,  was  otherwise 
negative.  The  range  of  his  temperature  is  shown  in  the  accom- 
panying chart  (Fig.  76). 

Discussion. — There  is  strong  tuberculous  taint  in  this  case,  as 
shown  by  the  family  history  and  the  early  pleurisy.  His  two  months' 
cough  and  his  frequent  attacks  of  "bronchitis"  strengthen  this  sus- 
picion, but  there  is  nothing  in  the  physical  examination  at  the  present 
time  that  points  to  any  tuberculous  lesion. 

He  has  been  in   countries  where  bilharzia  is  common,  but  the 


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77- 


2o8  DIFFERENTIAL  DIAGNOSIS 

absence  of  blood  and  eggs  in  his  stools  leaves  no  further  ground  for 
this  suspicion. 

Alcoholics  are  especially  subject  to  diarrhea.  This  patient  has 
taken  a  good  deal  of  alcohol,  and  if  no  other  explanation  can  be  found, 
it  may  seem  most  reasonable  to  blame  this  habit  for  his  symptoms. 

Can  his  high  blood-pressure  explain  the  condition  of  his  bowels? 
Various  writers  have  attempted  to  show  that  in  interstitial  nephritis, 
such  as  might  explain  his  hypertension,  a  compensatory  diarrhea 
occurs  as  an  expression  of  nature's  effort  to  rid  the  body  of  poisonous 
substances  normally  excreted  by  the  kidney.  I  have  never  been 
able  to  satisfy  myself,  however,  that  such  a  compensatory  diarrhea 
exists.  Moreover,  the  urine  shows  no  evidence  of  nephritis.  The 
enlarged  heart  and  high  blood-pressure  are  more  reasonably  explained 
as  part  of  a  general  arteriosclerosis. 

Why  should  we  not  adopt  the  patient's  own  suggestion — viz., 
a  food  diarrhea?  The  last  attack  is  more  easily  explained  in  this  way 
than  the  earlier  one,  which  occurred  when  he  was  taking  only  bread  and 
milk.  Nevertheless  this  was  the  best  explanation  which  we  could 
offer  and  it  seemed  to  be  confirmed  by  the  outcome. 

Outcome. — The  patient  was  given  only  water  by  mouth,  and 
after  twelve  hours  of  such  starvation  was  started  on  liquids  and  soft 
solids.  Food  was  excellently  well  borne.  He  had  no  diarrhea  after 
the  first  two  days.  The  stools  during  the  first  two  days  contained 
no  guaiac  reaction  and  no  other  evidence  of  consequence.  September 
2  2d  he  went  home  well. 

Case  78 

An  ItaHan  laborer  of  twenty  entered  the  hospital  September  21, 
1910.  His  family  history  and  past  history  were  negative.  His 
habits  include  the  use  of  three  or  four  beers  and  one  or  two  whiskies 
daily.  About  a  month  ago  he  began  to  have  moderate  diarrhea,  ac- 
companied by  abdominal  distention,  and  he  quit  work  for  two  weeks 
on  account  of  weakness.  For  the  past  eight  days  the  bowels  have 
moved  six  to  eight  times  daily.  He  has  had  an  occasional  attack  of 
pain  over  the  lower  left  ribs  in  the  axilla,  lasting  a  few  days  at  a  time. 
For  the  past  day  or  two  he  has  had  a  slight  dry  cough.  Five  weeks 
ago  he  weighed  140  pounds,  with  his  clothes.  At  entrance  he  weighed 
122  pounds,  without  clothes. 

Physical  examination  showed  a  boy  with  long  eyelashes  and  bright 
scleras.  The  heart  was  negative.  The  lungs  showed  the  appearance 
depicted  in  Figs.  77  and  78.    The  abdomen  was  distended,  and  flat  on 


DIARRHEA 


209 


Fig.  77. — Chest  signs  in  Case  78. 


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Vol.  11—14 


2IO 


DIFFERENTIAL   DIAGNOSIS 


percussion  in  the  flanks  and  over  the  pubes.  A  fluid  wave  was  pres- 
ent. The  right  epididymis  was  slightly  thickened.  Stools  negative. 
September  2  2d  the  abdomen  was  tapped  and  3350  c.c.  of  yellow, 
slightly  turbid  fluid  removed.  Its  specific  gravity  was  1019.  Albu- 
min, 3^  per  cent.  The  sediment  consisted  wholly  of  lymphocytes, 
90  per  cent,  of  which  were  of  small  size.  No  tubercle  bacilli  or  other 
organisms  were  found.  Cultures  were  negative.  Twenty  minims  of 
the  fluid  were  injected  into  a  guinea-pig  September  23d.  Autopsy 
of  this  pig  showed  nothing  abnormal.  The  range  of  the  temperature 
is  shown  in  the  accompanying  chart  (Fig.  79).  On  the  25th  of  Sep- 
tember he  complained  of  pain 
in  the  left  axilla  and  a  loud 
friction  sound  was  heard  there. 
Discussion. — The  associa- 
tion of  diarrhea  with  ascites, 
chest  pain,  cough,  fever,  and 
epididymitis  is  strongly  sug- 
gestive of  tuberculosis,  even 
though  the  guinea-pig  test  of 
the  ascitic  fluid  showed  noth- 
ing. That  the  temperature 
rapidly  subsided  after  rest  in 
bed  does  not  in  any  way  mili- 
tate against  this  diagnosis. 
The  character  of  the  ascitic 
fluid  is  wholly  consistent  with 
tuberculous  peritonitis,  and  the 
evidences  of  fluid  and  friction 
in  the  right  chest  confirms  it. 
Need  we  suppose  that  tuberculous  enteritis  was  also  present? 
There  seems  no  such  necessity,  especially  as  the  stools  were  negative 
and  by  no  means  excessively  frequent. 

Outcome. — By  October  5th  the  fluid  in  the  right  chest  was  disap- 
pearing and  the  friction-sounds  gone.  He  had  gained  10  pounds  and 
much  strength,  but,  as  he  was  still  unfit  for  work,  he  was  transferred, 
October  8th,  to  the  State  Hospital  at  Tewksbury.  Two  years  later  the 
Superintendent  of  the  Institution  writes  that  the  patient  remained 
there  from  October  8,  1910,  to  April  29,  191 1,  and  left  improved. 
On  October  11,  1910,  and  on  March  14,  1911,  the  right  chest  was 
tapped.  Each  time  45  ounces  of  amber-colored  fluid .  was  with- 
drawn. 


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DIARRHEA  211 

October  24,  19 10,  an  exploratory  laparotomy  was  done  and  the 
diagnosis  of  tuberculous  peritonitis  was  confirmed.  At  this  time  the 
patient  was  very  sick,  and  the  marked  improvement  which  occurred 
later  was  quite  unexpected. 

Case  79 

An  unmarried  woman  of  forty-four  was  seen  in  consultation  in 
September,  1910.  For  twenty  years  she  has  been  suffering  with  diar- 
rhea, alternating  with  short  periods  of  constipation.  Fifteen  years 
ago  she  spent  five  consecutive  years  in  bed,  and  since  then  has  fre- 
quently been  bedridden  for  months  at  a  time.  It  is  years  since  she 
has  ventured  outside  the  house,  and  she  never  takes  more  steps  than 
is  absolutely  necessary  within  the  house,  as  exercise  invariably  brings 
on  increased  diarrhea.  She  now  lives  quite  alone,  in  a  rural  district, 
getting  her  own  meals,  which  consist  exclusively  of  the  juice  chewed 
out  of  i^  pounds  of  broiled  steak,  per  day,  the  whey  from  2  quarts  of 
milk,  and  j  pint  of  heavy  cream.  This  is  absolutely  the  whole  of  her 
diet  and  has  been  the  same  for  some  years.  She  states  that  any  at- 
tempt to  eat  more  is  followed  by  an  increased  diarrhea  and  an  enor- 
mous production  of  "membrane"  within  the  bowel,  which  blocks  it 
and  sets  her  physicians  to  working  for  weeks  before  the  bowel  can  be 
made  to  move.  Her  appetite  is  good.  She  longs  to  eat  more,  but 
does  not  dare  to. 

The  patient  states  that  she  has  been  able  throughout  this  long 
illness  to  keep  her  mind  well  occupied  by  reading  and  sewing.  Con- 
siderable study  of  her  convinces  me  that  this  is  perfectly  correct, 
and  that  she  is  not  at  all  self-centered  or  morbid  in  any  way.  Ex- 
cept for  this  diarrhea  and  a  gradually  increasing  deafness  during  the 
past  six  years,  she  complains  of  nothing  and  has  an  excellent  family 
history. 

Physical  examination  shows  emaciation,  but  is  otherwise  negative. 
Blood  and  urine  show  nothing  abnormal.  Systolic  blood-pressure 
140  mm.  Hg. 

The  patient  stayed  nearly  nine  months  in  the  hospital,  which  she 
entered  weighing  70  pounds;  on  leaving  she  weighed  86f  pounds. 
During  the  first  three  months  of  her  stay  the  bowels  were  constipated 
and  at  no  time  in  the  nine  months  was  there  any  diarrhea.  Her 
pulse,  temperature,  and  respiration  were  always  normal  except  during 
an  inflammatory  complication,  to  be  referred  to  present^.  There 
was  always  a  guaiac  reaction  in  the  feces,  but  nothing  else  of  im- 
portance was  discovered,  despite  frequent  and  careful  examinations. 


212  DIFFERENTIAL   DL\GNOSIS 

Treatment  was  begun  with  the  patient's  usual  diet.  For  abdominal 
pain  she  was  given  hot  fomentations  and  a  daily  high  enema  of  warm 
oil.  October  3d  cornmeal  mush  and  ice-cream  were  added  to  the  diet. 
She  complained  of  much  pain  thereafter,  but  managed  to  retain  them 
and  slept  fairly  well  each  night.  October  6th  a  raw  egg  daily  was 
added.  October  12  th  hot  rice  with  cream  and  bread-crumbs  with 
beef- juice  were  added,  and  after  the  15th  of  the  month  she  took 
apple-sauce  or  the  juice  of  an  orange  daily.  In  the  open  ward  she 
did  not  do  well,  but  when  put  into  a  private  room  began  to  gain. 
Her  pain  was  still  severe^  sometimes  constant,  sometimes  in  parox- 
ysms, accompanied  by  abdominal  distention.  November  loth  toast  and 
milk  were  added  to  the  diet,  and  she  was  given^  despite  her  protes- 
tations, a  dropped  egg  on  toast.  When  she  found  that  she  could  eat 
this  without  increase  of  distress  and  much  relish,  her  spirits  were 
exuberant.  The  upright  position  and  attempts  to  walk  increased  her 
pain,  and  were  followed  by  periods  of  general  abdominal  tenderness 
and  rigidity.  Nevertheless,  she  was  urged  to  persevere,  and  suc- 
ceeded in  overcoming  her  discomfort. 

December  26th  she  began  to  have  great  pain  about  the  rectum 
and  perineum,  accompanied  by  a  slight  rise  of  temperature  and  a 
leukocytosis  of  18,000,  which  rose  January  4th  to  30,000,  when  a  vul- 
var abscess  was  opened  by  Dr.  Cobb  and  50  to  100  c.c.  of  foul  pus, 
containing  colon  bacilh,  evacuated.  It  took  her  until  about  the  19th 
of  January  to  get  over  this.  The  oil  enemata  were  increased  about 
this  time  to  16  ounces  every  night.  This  enema  was  followed  by  a  feel- 
ing of  great  comfort  and  enabled  her  to  sleep.  After  February  ist  she 
gradually  increased  her  walking  distance  until  she  was  able  to  walk 
an  eighth  of  a  mile  within  the  hospital  and  to  take  Zander  exercises 
without  discomfort.  By  May  she  appeared  really  perfectly  well, 
though  subject  to  occasional  attacks  of  abdominal  pain.  She  was 
eating  everything,  including  many  foods  which  she  had  not  taken  for 
twenty  years. 

Discussion. — This  case  is  remarkable  in  several  respects.  First, 
in  that  a  woman  who  had  lived  the  life  of  an  invalid  for  twenty  years 
and  had  not  been  able  to  cross  the  threshold  of  her  house  for  at  least 
a  decade  was  restored  to  perfect  health,  practically  without  any 
treatment  except  diet.  Her  recovery  would  have  been  impossible,  I 
think,  but  for  her  unusual  force  of  character,  for  several  times  in  the 
course  of  her  treatment  her  sufferihgs  were  very  great,  and  any  but  a 
very  determined  person  would  have  given  up  the  effort  to  eat  unac- 
customed food  and  returned  to  starvation  diet. 


DIARRHEA  213 

At  times  the  abdominal  distention  and  pain  were  so  severe  that  but 
for  the  normal  temperature  and  pulse  she  would  have  undoubtedly 
been  operated  upon. 

In  view  of  the  outcome  of  the  case,  I  believe  that  her  sufferings 
were  wholly  due  to  constipation,  with  resulting  irritation  and  ulcera- 
tion of  the  bowel.  At  times  the  case  took  on  the  features  of  colica 
mucosa,  but  most  of  the  time  the  symptoms  were  simply  those  of  con- 
stipation. Practically  no  medicine  was  given  by  mouth,  but  she  got 
great  relief  from  her  pain  by  the  enemata  of  olive  oil. 

No  bismuth  it;-rays  were  taken  in  this  case,  but  it  closely  resembled, 
on  the  clinical  side,  many  that  get  operated  upon  for  adhesions. 
I  should  like  at  this  point  to  express  my  behef  that  when  patients 
improve  after  operations  done  for  the  relief  of  adhesions,  the  relief  is 
not  due  to  the  operation,  except  in  rare  cases.  It  is  just  now  the 
fashion  to  lay  great  stress  upon  adhesions,  veils,  or  membranes  about 
the  cecum,  about  the  gall-bladder,  and  the  pyloric  end  of  the  stomach, 
but  I  am  convinced  as  a  result  of  my  study  of  cases,  postmortem  and 
antemortem,  that  such  membranes  and  adhesions  rarely  cause  any 
symptoms,  and  that  the  symptoms  attributed  to  them  are  just  as 
frequent  in  patients  having  no  adhesions.  The  present  fad  for  oper- 
ating on  such  cases  rests  upon  evidence  as  unsatisfactory  as  that  which 
led  us  a  few  years  ago  to  operate  upon  so-called  floating  kidneys,  and 
to  make  diagnoses  of  "auto-intoxication,"  "hthemia,*'  and  "ptomain- 
poisoning." 

It  must  be  admitted  that  many  patients  improve  after  operations 
for  the  relief  of  adhesions,  but  I  believe  that  this  improvement  is  to 
be  explained  by  the  dietetic,  hygienic,  and  psychic  regime  to  which  the 
patient  is  submitted  after  the  operation.  Some  patients  cannot  be 
induced  to  diet  or  to  submit  themselves  to  any  regime  unless  some  sort 
of  an  operation  is  performed.  This  sort  of  irrationaUty  is  parallel . 
to  the  fooUshness  of  those  who  would  not  stop  overeating  and  over- 
drinking unless  they  are  sent  to  some  spa  or  springs  to  drink  a  large 
quantity  of  disagreeable  water.  But  it  seems  to  me  altogether  un- 
necessary and  wrong  for  the  medical  profession  to  encourage  people 
in  such  wasteful  and  ridiculous  performances.  In  the  long  run  the 
pubhc  will  not  thank  us  for  helping  them  to  deceive  themselves  and  to 
waste  their  money. 

Outcome. — She  left  the  hospital  May  5th,  1911 ,  but  was  heard  from 
subsequently  as  enjoying  splendid  health  and  getting  back  into  the 
world  of  affairs  which  had  been  unknown  to  her  for  many  years. 
Ischiorectal  abscess  later  developed  and  was  operated  on  at  the 


214  DIFFERENTIAL   DL\GNOSIS 

Baptist  Hospital  by  Dr.  Hugh  Cabot,  after  which  she  made  a  good 
recovery  and  has  remained  well  since  (1914). 

Case  80 

A  married  woman  of  twenty-four  entered  the  hospital  September 
29,  1910,  with  a  diagnosis  of  "tubercular  enteritis."  Her  family  his- 
tory was  negative  and  she  herself  has  always  been  well  except  for  an 
occasional  ''summer  diarrhea,"  never  lasting  more  than  a  week. 
She  has  two  children,  the  youngest  fourteen  months  old.  This  child 
she  nursed  until  two  or  three  days  ago. 

For  nine  weeks  there  has  been  steady  diarrhea,  first,  three  move- 
ments a  day,  but  lately  increasing  until  she  says  that  movements  come 
every  ten  minutes  and  feel  like  hot  water.  For  a  week  there  has  been 
considerable  blood  in  them  and  always  much  mucus.  For  a  fortnight 
she  vomited  after  nearly  every  meal,  and  once  last  week  raised  a  tea- 
spoonful  of  blood.  She  has  had  sHght  dry  cough  for  nine  weeks,  but 
never  raised  blood.  Up  to  a  week  ago  she  kept  at  work,  but  since 
that  time  severe  and  frequent  abdominal  cramps  doubled  her  up  and 
compelled  her  to  stay  in  bed.  Previously  her  diarrhea  had  been 
nearly  painless. 

Her  appetite  and  sleep  were  very  poor.  Her  best  weight,  two  years 
ago,  was  138  pounds;  six  weeks  ago,  97  pounds;  now,  without  clothes, 
81  pounds. 

The  patient  was  emaciated  and  pale,  with  flushed  cheeks.  A  few 
squeaks  were  heard  at  the  right  apex,  where  the  physiologic  dulness 
seemed  to  be  increased.  Otherwise  the  chest  was  negative.  The  ab- 
domen was  concave  and  acutely  tender  throughout.  Coils  of  intestine 
could  be  seen  and  felt  in  it.  The  stools,  examined  every  day  or  two 
for  three  weeks,  showed  no  reaction  to  guaiac  and  no  other  features 
of  importance.  Tubercle  bacilli  were  never  found.  Blood  and  urine 
were  normal.  Blood-pressure,  105  mm.  Hg.,  systolic;  80  mm.  Hg., 
diastolic.     Temperature,  pulse,  and  blood  normal. 

The  patient  was  put  on  a  Schmidt  diet  with  subnitrate  of  bismuth, 
I  dram  four  times  a  day,  and  a  suppository  of  gall  and  opium,  when 
needed  for  pain.  The  movements  were  five  or  six  daily  during  the  first 
three  days.  After  that  there  was  no  diarrhea  in  three  weeks'  observa- 
tion. The  officinal  pill  of  camphor,  opium,  and  tannin  was  given  four 
times  a  day  for  four  days,  beginning  October  ist.  After  that  no 
medicine  was  needed  except  high  oil  enema  daily. 

Discussion. — In  all  probabiUty  this  patient  had  a  mild  tubercu- 
losis at  the  right  apex,  and,  admitting  that,  many  a  physician  would 


DIAREHEA  215 

conclude  at  once  that  the  diarrhea  must  be  due  to  tuberculous  enteritis. 
That  this  is  often  a  mistake  I  have  shown  elsewhere.^  Not  every  case 
of  diarrhea  associated  with  pulmonary  tuberculosis  is  due  to  tubercu- 
lous enteritis.  A  quite  curable  non-tuberculous  enteritis  is  common 
in  such  cases,  and  this  fact  is  of  much  importance  in  prognosis.  The 
patient's  response  to  treatment  in  this  case  made  it  very  improbable 
that  there  was  any  tuberculosis  in  the  bowel. 

The  tenderness  of  the  abdomen  and  the  visible  peristalsis  gave  rise 
in  this  case,  as  they  frequently  do,  to  unnecessary  anxiety.  Peritoni- 
tis and  obstruction  were  suspected,  but  in  view  of  the  normal  tempera- 
ture and  pulse,  the  normal  blood,  and  the  frequent  stools  there  was 
never  any  good  reason  for  anxiety.  Such  tenderness  and  peristalsis 
are  common  when  enteritis  occurs  in  an  emaciated  person. 

The  rapid -disappearance  of  a  diarrhea  which  lasted  nine  weeks  is 
due  largely,  I  think,  in  this  case  to  rest  in  bed.  It  will  be  noted  that 
the  patient  had  kept  at  work  until  a  week  before  her  entrance  to  the 
hospital.  I  know  no  disease  comparable  to  enteritis  in  the  rapidity 
of  benefit  produced  by  rest  in  bed  and  change  in  environment,  even 
when  no  dietetic  or  medicinal  remedies  are  used.  Since  blood  and 
pus  were  absent  from  the  stools,  we  have  no  good  reason  to  suppose 
that  any  ulcerations  were  present  in  the  bowel.  The  exact  cause  of 
the  diarrhea  is  obscure,  as  it  is  in  a  very  large  number  of  mild  cases. 

We  cannot  reasonably  assume  that  colitis  or  any  other  anatomic 
change  is  present.  The  trouble  may  well  be  due  to  anomalies  of  secre- 
tion, of  motihty,  or  to  some  circulatory  disturbance.  The  latter  is 
somewhat  suggested  by  the  low  blood-pressure. 

Outcome. — By  October  3d  she  looked  and  felt  like  a  different  per- 
son. The  appetite  rapidly  increased,  and  by  October  9th  she  had 
gained  9  pounds.  From  that  time  until  her  discharge,  October  2 2d, 
she  gained  steadily  in  weight  and  strength,  and  when  discharged 
weighed  94  pounds,  an  increase  of  13  pounds. 

Case  81 

A  weaver  of  thirty,  born  in  Finland,  entered  the  hospital  October  14, 
1910.  Ten  years  ago  he  was  in  bed  a  week  with  diarrhea  and  ex- 
pelled a  tapeworm  20  feet  long.  Otherwise  he  has  been  well  and 
denies  venereal  disease.  He  confesses  that  every  now  and  then 
he  is  in  the  habit  of  drinking  a  pint  or  so  of  straight  alcohol,  when 
his  wife  happens  to  have  it  in  the  house  for  non-medicinal  purposes. 

^  "  Causes,  Types,  and  Treatment  of  Diarrhea  in  Adult  Life,"  Journal  of  the  American 
Medical  Association,  September  27,  19 13. 


2l6  DIFFERENTIAL  DL\GNOSIS 

For  one  year  he  has  been  disabled  by  a  persistent  diarrhea,  ten 
or  twelve  movements  occurring  daily.  During  this  time  he  has  eaten 
enormously,  often  feeling  so  full  after  supper  that  he  could  scarcely 
walk,  yet  still  hungry.  For  four  months  last  winter  he  would  vomit 
after  each  meal,  but  immediately  after  vomiting  would  devour  more 
food  in  a  vain  effort  to  appease  his  inordinate  appetite.  His  wife  now 
works  and  so  keeps  him  supplied  with  food. 

The  patient  is  found,  on  physical  examination,  to  be  moderately 
obese.  Otherwise  external  examination  is  entirely  negative.  Like- 
wise the  blood  and  urine.  The  systolic  blood-pressure  is  from  i6o  to 
165  mm.  Hg.;  diastolic,  no  mm.  Hg. 

On  a  Schmidt  test-diet  there  is  no  diarrhea,  and  after  two  days 
he  is  given  house  diet,  which  also  produces  no  diarrhea.  His  wife 
avers  that  his  "insides  must  have  been  burnt,"  for  until  she  stopped 
using  alcohol  for  household  purposes  he  was  constantly  consuming  it, 
undiluted,  until  he  became  so  drunk  that  he  could  not  move.  Since 
she  has  stopped  buying  alcohol  he  has  been  better.  October  21st 
he  left  the  hospital,  apparently  in  perfect  health. 

Discussion. — The  association  of  diarrhea  with  alcohoHsm  is  a 
very  familiar  one,  and  in  view  of  the  negative  findings,  on  physical 
examination,  I  see  no  reason  to  doubt  that  alcohol  was  the  cause  of 
all  this  patient's  troubles.  It  is  very  striking  that  a  man  who  has 
had  diarrhea  for  an  entire  year  should  get  over  it  within  a  week, 
in  fact,  within  forty-eight  hours,  as  a  result  of  nothing  in  the  world 
but  abstention  from  alcohol  and  rest  in  bed.  Such  cases,  however,  are 
very  familiar  and  have  already  been  referred  to.  No  doubt  his 
habits  of  gourmandizing  also  played  a  part  in  upsetting  him. 

I  would  call  attention  to  the  fact  that  no  medicine  and  no  anti- 
diarrhea  diet  was  given  in  this  case. 

Case  82 

An  English  laborer  of  forty-three  entered  the  hospital  October  21, 
1910,  for  a  continuous  diarrhea  of  six  months'  duration,  averaging 
three  or  four  watery,  sometimes  bloody,  movements  a  day.  In  this 
period  he  had  lost  50  pounds,  his  usual  weight  being  160  pounds,  and 
had  become  very  weak.  Attempts  to  work  had  been  quite  futile. 
There  has  been  considerable  burning  pain  in  the  left  iliac  fossa  and  the 
epigastrium  and  some  colic  before  stools.  He  continued  to  eat  ordi- 
nary food,  with  good  appetite,  and  no  vomiting,  but  frequently  felt 
chilly,  especially  in  the  evening.  For  the  past  four  or  five  months 
he  had  had  a  slight,  dry  cough.     His  previous  history  was  good  and 


DIARRHEA 


217 


he  had  never  been  farther  south  than  Baltimore.  The  past  eleven 
months  he  had  been  living  in  New  Hampshire,  but  has  been  told  that 
several  people  in  his  neighborhood  also  had  dysentery. 

His  stools  were  examined  thirty-three  times  during  his  five  weeks' 
stay  in  the  hospital.  The  guaiac  test  was  positive  eight  times,  and 
negative  in  the  remainder,  otherwise  there  was  nothing  remarkable  on 
gross  or  microscopic  examination.  Culture  from  the  stools  showed  the 
colon  bacillus  as  the  only  micro-organism  present. 

The  patient  was  fairly  nourished.  Along  and  behind  the  right 
sternomastoid  muscle  was  a  chain  of  very  hard,  movable,  non-tender 


croitVvles, 

No 


Fig.  80. — Signs  in  Case  82  at  entrance. 


glands,  the  size  of  a  pea  to  that  of  a  bean,  partly  conglomerate,  not 
attached  to  the  skin.  The  axillary  and  inguinal  glands  were  some- 
what enlarged.  The  epitrochlears  were  enlarged  on  both  sides. 
Lungs  showed  the  lesions  pictured  in  Figs.  80,  81;  x-rsij  examination 
showed  extensive  involvement  of  the  left  lung,  as  low  as  the  fifth 
rib,  apparently  an  old  infiltration  and  largely  healed.  The  right 
lung  also  showed  involvement  down  as  far  as  the  third  rib.  The 
temperature  was  as  in  the  accompanying  chart  (Fig.  82).  Abdomen 
was  dull  everywhere  except  in  the  left  upper  quadrant.  There  was 
general  tenderness  on  deep  pressure.  Otherwise  physical  examina- 
tion was  not  remarkable.     The  diarrhea  ceased  after  the  first  two 


2l8 


DIFFERENTIAL   DL\GNOSIS 


weeks  of  hospital  care.     During  the  last  four  weeks  of  his  stay  in 
the  hospital  he  had  absolutely  no  sputum  and  almost  no  cough. 


Fig.  8i. — Signs  in  Case  82  at  entrance. 

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The  diarrhea  had  entirely  ceased  after  he  was  put  to  bed,  November 
13th.     His  weight  on  leaving  the  hospital  was  107  pounds,  within 


DIARRHEA 


219 


a  pound  of  that  with  which  he  entered.     Apparently,  rest  in  bed  was 
the  treatment  which  helped  him  most.     Fat-free  diet  and  colonic  irri- 


Fig.  83. — Signs  in  Case  82  on  November  24th. 


rorifixvii 

bre,a.t\\\Y\i 


Fig.  84. — Signs  in  Case  82  on  November  24th. 

gations  with  i-dram  doses  of  bismuth,  three  times  a  day,  gave  him  no 
special  relief;  Figs.  83  and  84  show  the  lesions  found  November  24th. 


2  20  DIFFERENTIAL   DLA.GNOSIS 

Discussion. — This  case  presents  the  picture  of  a  diarrhea  continu- 
ous for  six  months  in  a  patient  showing  extensive  pulmonary  lesions, 
in  all  probability  tuberculous.  Although  there  is  no  pus  in  the  stools, 
the  frequent  presence  of  the  guaiac  reaction  makes  it  not  improbable 
that  intestinal  ulcerations  are  present.  This  is  not  negatived  by  the 
fact  that  no  diarrhea  occurred  after  he  was  put  to  bed.  This  is  often 
the  case  in  ulcerative  colitis. 

The  chief  point  of  doubt  is  whether  or  not  the  diarrhea  is  of  tuber- 
culous origin.  The  fact  that  it  complicates  pulmonary  tuberculosis 
in  no  way  proves  that  the  colitis  is  tuberculous.  (For  further  dis- 
cussion of  this  point  see  Case  No.  80.)  Even  the  finding  of  tubercle 
bacilli  in  the  stools  would  not  prove  that  the  intestinal  lesions  were 
tuberculous,  since  the  bacilli  may  come  from  swallowed  sputa.  The 
main  point  to  be  insisted  upon  in  this  case  is  that  if  the  patient  can 
master  his  pulmonary  tuberculosis,  there  is  not  necessarily  any  incur- 
able complication  in  the  intestine  to  cloud  the  outlook. 

The  examination  of  the  stools  makes  it  unlikely  that  any  specific 
type  of  infection  (Amoeba  histolytica  or  Shiga's  bacillus)  is  present. 

Outcome. — The  patient  went  home  November  25,  1910,  and  died 
February  12,  191 1.  The  diarrhea  continued  unchecked.  There  were 
no  pulmonary  symptoms. 

Case  83 

A  kitchen  man  of  thirty-five,  born  in  Russia,  entered  the  hospital 
September  13,  19 10.  The  patient  is  a  steady  drinker  and  occasionally 
gets  drunk.  He  also  smokes  to  excess.  He  has  had  no  previous  sick- 
ness except  typhoid,  which  he  had  in  Russia  many  years  ago.  Three 
or  four  weeks  ago  he  began  to  be  bothered  by  diarrhea,  eight  or  ten 
watery  movements  a  day,  without  blood  or  tenesmus.  At  the  same 
time  he  had  severe,  almost  constant,  headache,  occasional  attacks  of 
vomiting,  and  on  exertion  experienced  a  pain  referred  to  the  hepatic 
area.  He  has  also  noticed  shortness  of  breath,  with  palpitation  and 
precordial  pain  on  exertion. 

Physical  examination  showed  good  nutrition.  Pupils  slightly 
irregular,  otherwise  normal.  Glands  and  reflexes  negative.  The  left 
border  of  cardiac  dulness  extended  13  cm.  from  the  median  line  and 
was  outside  of  the  nipple.  Right  border  5  cm.  from  midsternal  line. 
There  was  some  increase  in  the  width  of  the  dull  area  behind  the  man- 
ubrium and  a  palpable  impulse  in  the  suprasternal  notch.  There 
was  a  harsh  systolic  murmur  at  the  apex,  transmitted  inward  and 
outward.     In  the  axilla  a  diastolic  murmur  was  heard.     In  the  second 


DIARRHEA 


221 


right  interspace  there  was  a  blowing  systoHc  murmur,  different  in  pitch 
and  quality  from  that  at  the  apex.  The  aortic  second  was  high 
pitched,  sharp,  and  ringing.  The  pulses  showed  no  Corrigan  quality. 
The  arteries  were  thickened,  tortuous,  and  in  places  beaded.  Blood- 
pressure  i6o  mm.  Hg.,  systolic,  at  entrance;  105  mm.  Hg.,  diastohc. 
The  lungs  showed  dulness  and  a  few  fine  crackles  at  each  base  behind. 
The  liver  extended  from  the  sixth  interspace,  mammary  line,  to  a 
point  four  fingers  below  the  ribs,  where  an  edge  was  indistinctly  felt. 
Manipulation  of  this  region  caused  pain  and  dilatation  of  the  neck 
veins.     The  spleen  was  felt  two  fingers'  breadth  below  the  ribs  and 


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its  percussion  area  was  enlarged.     The  blood  was  negative.    Tem- 
perature as  shown  in  the  accompanying  chart  (Fig.  85.) 

The  urine  averaged  25  ounces  in  twenty-four  hours  during  the  first 
week  of  his  stay  in  the  hospital;  after  that,  from  40  to  50  ounces;  this 
increase  corresponding  with  a  fall  in  blood-pressure  to  135,  and  on  the 
4th  of  October  to  125.  Diastolic  pressure  varied  very  Httle  during 
these  changes.  The  specific  gravity  of  the  urine  varied  from  1008  to 
1012,  with  a  slight  trace  of  albumin,  many  hyaline,  granular,  and 
cellular  casts,  and  a  little  blood,  free  and  adherent.  Later  in  the 
course  of  the  disease  casts  were  almost  impossible  to  find.  On  the 
i8th  of  September  the  red  cells  numbered  4,300,000;  hemoglobin,  60 


2  22  DIFFERENTLA.L  DLA.GNOSIS 

per  cent.  The  reds  showed  moderate  achromia.  The  patient  had  at 
this  time  no  s^-mptoms  whatever,  seemed  bright  and  happy.  He 
was  given  potassium  iodid  and  hydrargyrum  until  salivation  was 
produced,  but  without  any  effect  upon  the  temperature  or  other 
physical  signs.     Blood-cultures  were  negative. 

The  heart  signs  did  not  change  at  all,  but  toward  the  middle  of 
September  there  was  a  little  edema  over  the  sacrum  and  in  the  legs. 
By  the  last  of  the  month  he  was  obviously  losing  ground.  On  the 
28th  he  had  a  profuse  nosebleed,  requiring  to  be  packed.  The  next 
day  the  blood  showed:  red  cells,  3,000,000;  white,  4500;  hemoglobin, 
54  per  cent.  The  second  blood-culture  showed  again  negative  results. 
The  saHvation  produced  by  mercury  continued  into  the  early  part  of 
October.  At  this  time  the  diastolic  murmur  could  clearly  be  heard 
along  the  left  border  of  the  sternum.  Pulmonic  second  sound  was 
reduplicated.  There  was  no  thrill  an^^where.  The  fundus  of  the 
eye  was  normal. 

Discussion. — Headache  and  dyspnea  are  not  symptoms  of  any 
form  of  enteritis,  and  suggest  at  once  that  this  patient's  diarrhea  is 
symptomatic  of  some  non-intestinal  disease.  The  blood-pressure 
and  the  condition  of  the  urine  strongly  suggest  chronic  nephritis, 
probably  of  the  glomerular  t5^e.  The  nosebleeds  further  support 
this  diagnosis. 

Beyond  this  the  early  arterial  changes,  the  splenic  enlargement, 
and  the  evidences  of  aortic  regurgitation,  without  previous  history  of 
rheumatism,  chorea,  or  sore  throat,  lead  us  to  consider  syphilis  as  a 
possible  cause  for  his  symptoms.  (Note  the  positive  Wassermann 
reaction  obtained  at  the  Boston  City  Hospital  and  recorded  below 
imder  Outcome.) 

A  glance  at  the  chart  reveals  a  fever  not  well  accounted  for  either 
by  glomerular  nephritis  or  by  late  syphiHs,  such  as  he  must  have  if 
there  was  any  syphilis  about  him.  Neither  of  these  diseases  causes 
such  a  fever  as  this  patient  had.  This  fact  should  have  made  us  sus- 
pect that  the  cardiac  murmurs  might  be  due  to  an  acute  endocarditis, 
even  though  leukocytes  were  normal. 

Outcome. — On  the  13th  of  October  he  was  transferred  to  Tewks- 
bury  Hospital,  where  he  stayed  two  months  without  improvement, 
and  then  went  to  the  Boston  City  Hospital,  where  his  condition  was 
essentially  the  same  as  that  previously  recorded,  blood-pressure.  May 
22,  191 1,  being  130  mm.  Hg.  The  Wassermann  reaction  at  this  time 
was  strongly  positive.  On  the  14th  of  September  hemorrhages  were 
found  in  the  fundus  of  the  right  eye.     On  the  17th  of  June,  191 1,  after 


DIARRHEA  223 

a  gradual  failure  and  slight,  irregular  temperature,  edema,  hydro- 
thorax,  ascites,  and  anasarca,  the  patient  died. 

Autopsy  showed  subacute  infectious  endocarditis  of  the  mitral  and 
aortic  valves;  heart's  weight,  775  grams;  chronic  glomerulonephritis. 

It  is  interesting  to  speculate  here  whether  the  nephritis  was  the 
cause  of  the  endocarditis  or  vice  versa.  Libman's  studies  of  subacute 
bacterial  endocarditis  (endocarditis  lenta)  led  him  to  believe  that 
chronic  glomerula  nephritis  is  often  a  result  of  emboli  thrown  off  from 
an  inflamed  heart-valve.  In  view,  however,  of  the  enormous  size  of 
the  heart  in  this  case,  it  seems  more  probable  that  the  nephritis  has 
existed  for  a  long  time,  and  that  the  endocarditis  should  be  regarded 
as  a  manifestation  of  lowered  resistance  to  infection,  dependent  upon 
the  nephritis. 

Case  84 

A  metal  polisher  of  twenty-eight,  born  in  Russia,  entered  the  hospi- 
tal May  7,  1 910.  For  six  years,  beginning  eleven  years  ago,  he  has 
been  a  sailor,  and  has  visited  Australia,  India,  Egypt,  Turkey,  and 
Chili.  The  last  five  years  he  has  done  metal  polishing,  chiefly  of  brass, 
and  uses  an  emery  wheel,  but  has  considered  himself  well  until  the 
present  illness. 

Diarrhea  and  cramps  began  two  years  ago  and  have  been  present 
continuously  ever  since,  except  for  short  intervals,  never  exceeding 
a  week  in  duration.  The  cramps  are  never  severe  or  localized  and 
never  radiate  upward  or  downward.  They  precede  stools,  and  are 
brought  on  by  exertion,  by  soups,  fruits,  or  large  meals.  His  stools 
are  brown  and  never  contain  blood.  Bowels  move  every  two  hours 
at  night  and  somewhat  less  frequently  during  the  day.  He  is  always 
hungry  and  has  no  nausea  or  vomiting,  but  is  afraid  to  eat  because 
of  the  effect  upon  his  bowels.     He  has  lost  7  pounds  in  two  years. 

The  patient  is  well  nourished,  but  markedly  pale.  He  appears 
to  have  two  radial  arteries  in  his  right  wrist.  Chest,  abdomen,  and 
extremities  show  nothing  abnormal.  Urine  is  normal.  Blood  con- 
tains 13,500  leukocytes  per  cubic  millimeter,  6  per  cent,  of  them  being 
eosinophils.  Red  cells  show  slight  achromia  and  some  varieties  in 
size.  Feces  show  flagellates  in  great  numbers,  their  rapid  motion 
preventing  accurate  identification.  An  occasional  egg  of  the  tricho- 
cephalus  is  seen.  The  guaiac  reaction  is  always  positive,  but  there  is 
no  pus  or  obvious  blood,  no  mucus  or  excess  of  food  elements.  On 
the  8th  of  May  two  or  three  amebae  are  seen  in  active  motion.  The 
endoplasm  is  gradually  and  easily  distinguished  from   the  highly 


224  DIFFERENTIAL   DIAGNOSIS 

refractive  ectoplasm,  even  when  the  amebae  are  at  rest.  The  diam- 
eter seems  to  be  from  35  to  50  microns.  The  nucleus  is  not  made 
out  and  there  is  no  contractile  vacuole.  One  inclusion,  apparently 
a  red  corpuscle,  is  seen.  Charcot-Leyden  crystals  are  numerous, 
some  of  them  50  microns  in  length. 

Discussion. — This  patient  raises  the  question  how  we  are  to  differ- 
entiate the  harmless  Amoeba  coli  from  the  pathogenic  ameba,  ordi- 
narily known  as  the  Amoeba  histolytica  or  the  ameba  of  dysentery. 
The  histologic  and  tinctorial  differentiae  will  be  referred  to  presently. 
Meantime,  it  is  obvious  that  this  patient  has  visited  a  number  of 
countries,  in  any  of  which  he  might  have  picked  up  amebic  dysen- 
tery. This  disease  is  still  further  suggested  by  the  long  duration  of 
the  diarrhea  and  by  the  apparent  efi&ciency  of  the  ipecac  treatment. 
(See  below.) 

The  more  important  distinctions  between  the  harmless  ameba 
and  the  dysenteric  ameba  are  as  follows: 

1.  The  dysenteric  ameba,  or  Amoeba  histolytica,  is  more  active 
in  its  movements,  and  these  movements  often  persist  for  hours  in  the 
cold,  while  the  harmless  ameba  (Amoeba  coli)  is  always  more  sluggish 
and  soon  loses  its  movements  at  room  temperature. 

2.  The  dysenteric  ameba  much  more  often  contains  red  corpuscles 
and  other  cells  within  its  protoplasm.  The  harmless  ameba  rarely 
takes  these  up. 

3.  In  stained  specimens  the  Amoeba  histolytica  shows  an  indis- 
tinct nucleus  containing  but  little  chromatin,  while  the  Amoeba  coli 
has  a  much  clearer  nucleus,  containing  abundant  chromatin. 

In  the  encysted  state  the  Amoeba  histolytica  has  a  smaller,  less 
refractive,  and  thinner  cyst,  and  usually  contains  the  elongated  refract- 
ive so-called  "chromidial"  bodies,  which  are  not  found  in  the  Amoeba 
coli.  In  this  encysted  state  the  nuclei  of  the  Amoeba  histolytica  are 
never  more  than  4,  while  those  of  the  Amoeba  coli  are  8  or  more.^ 

Outcome. — The  patient  was  given  a  diet  of  liquids  and  soft  solids 
and  the  bowel  was  irrigated  with  i  quart  of  quinin  solution,  i:  2500. 
Following  this  the  diarrhea  ceased  and  no  amebae  could  be  found  dur- 
ing the  last  ten  days  of  his  stay  in  the  hospital.  The  bowel  move- 
ments were  formed  and  occurred  but  once  daily.  He  left  the  hospital, 
much  improved.  May  20th,  but  returned  November  29th,  stating 
that  for  two  months  after  his  last  treatment  at  the  hospital  he  was 
quite  well,  then  his  diarrhea  gradually  returned  and  has  continued 

^  Walker  and  Sellards,  Philippine  Journal  of  Science,  Section  B,  vol.  viii,  No.  4, 
August,  1913. 


DIARRHEA  225 

since,  though  he  has  gained  4  or  5  pounds  since  he  was  last  in  the 
hospital  and  has  worked  until  five  days  ago.  At  this  time  no  amebae 
could  be  found  in  the  stools.  Nevertheless,  he  was  given  the  ipecac 
treatment,  namely,  10  gr.  of  ipecac  in  salol-coated  pills  twice  a  day 
for  three  days;  then,  later,  the.  same  dosage  for  nine  days.  Quinin 
irrigations,  i :  2000,  were  also  given  daily.  The  stools  occurred  only 
once  or  twice  a  day  during  his  stay  in  the  hospital.  His  weight  at 
this  time  was  10  pounds  greater  than  at  his  last  entrance  and  the 
eosinophils  made  up  i  per  cent,  of  the  leukocytes  present.  December 
19th  he  was  discharged  considerably  relieved. 

Case  85 

A  meat  packer  of  twenty-two,  born  in  Greece,  entered  the  hospital 
January  23,  191 1.  The  patient  had  always  been  perfectly  well  ex- 
cept that  once,  six  months  ago,  he  had  been  laid  off  for  three  days 
with  a  condition  similar  to  the  present.  For  the  past  three  months  he 
had  felt  unduly  tired.  His  bowels  move  from  three  to  five  times  a 
day.  Duration  of  this  diarrhea  not  clearly  made  out.  (See  Out- 
patient Department  record  No.  154,759.)  Patient  had  lost  no  weight 
and  had  had  no  trouble  with  his  urine.  His  appetite  was  excellent 
and  he  had  worked  until  four  days  before  entry. 

Physical  examination  was  entirely  negative  except  as  related  to 
the  stools,  which  contained  in  each  slide  examined  a  few  eggs  Uke  those 
shown  in  the  accompanying  figures.  Twice  a  free-swimming  cihated 
embryo  was  seen.  There  was  a  good  deal  of  pus  and  mucus  and  a 
little  blood  in  the  well-formed  stools. 

After  the  first  day  in  bed  there  was  no  diarrhea  for  a  week.  After 
that  he  began  to  have  three  or  four  stools  a  day.  Rectal  examina- 
tion showed  numerous  polypoid  projections,  |  to  i  cm.  long  and  about 
the  same  in  thickness,  but  no  ulcers.  One  of  these  pol5^s  was  re- 
moved and  showed,  on  microscopic  examination  of  paraffin  sections, 
a  tissue  richly  infiltrated  with  plasma-cells  and  some  leukocytes, 
in  the  midst  of  which  were  eggs  and  embryos  of  the  Schistosoma 
haematobium,  surrounded  by  giant-cells.  Atypical  epitheHal  tubules, 
like  those  of  the  rectal  mucous  membranes,  were  also  seen. 

The  patient  was  given  "606,"  0.6  gram  into  a  muscle,  but  no 
particular  effect  was  observed. 

Discussion. — The  findings  on  rectal  examination  and  stool  ex- 
amination make  any  discussion  of  differential  diagnosis  unnecessary. 
The  eggs  shown  in  Figs.  86  and  87  are  entirely  characteristic  of  bil- 
harzia  disease.     This  parasite,  as  is  well  known,  affects  usually  the 

Vol.  11—15 


226 


DIFFERENTIAL  DIAGNOSIS 


bladder,  the  rectum,  or  both,  producing  a  most  intractable  form  of 
chronic  inflammation. 


Fig.  86. — ^Unruptured  bilharzia  eggs.  Note  the  lateral  spine  in  each.  (Photographs 
by  L.  S.  Brown,  of  the  Pathological  Laboratory  of  the  Massachusetts  General  Hospital. 
The  case  was  under  the  care  of  Dr.  Arthur  K.  Stone,  by  whose  kind  permission  it  is  re- 
ferred to  here.) 

This  patient  was  taken  into  the  hospital  in  order  to  see  whether 
the  effectiveness  of  salvarsan  upon  some  organisms  of  the  protozoan 
group  extends  to  bilharzia  disease.  The  outcome  showed  that  there 
was  apparently  no  such  action. 


Fig.  87. — Ruptured  bilharzia  eggs.  Near  one  the  free  embryo  is  visible.  (Photo- 
graphs by  L.  S.  Brown,  of  the  Pathological  Laboratory  of  the  Massachusetts  General 
Hospital.) 

Outcome. — The  patient  came  in  again  on  June  i,  191 1,  stating  that 
since  leaving  the  hospital,  February  17th,  he  has  had  three  or  four 
movements  a  day,  usually  with  some  blood,  but  has  worked  con- 


DIARRHEA  227 

tinuously.  The  condition  was  exactly  as  before,  and,  after  staying 
in  the  wards  a  couple  of  weeks  and  gaining  4  pounds,  he  was  allowed 
to  go  home  again.  His  blood  on  this  occasion  showed  9  per  cent,  of 
eosinophils  in  a  total  leukocyte  count  of  12,000. 

September  14,  191 2,  the  patient  came  to  the  dispensary  for  pains 
in  the  "calves"  of  both  his  legs,  also  a  bad  headache,  especially  on  the 
left  side,  and  slight  pains  in  his  abdomen.  Examination  of  the 
stools  showed  spatters  of  soft,  brick-red  juice.  Bilharzia  eggs  present. 
No  food  seen.  Many  soap  and  fatty  acid  crystals.  Guaiac  test 
positive.     Pus-cells  and  blood  present. 

Case  86 

A  telephone  operator  of  thirty-two  entered  the  hospital  March  21, 
191 1.  His  family  history  was  entirely  negative,  and  he  had  been  quite 
well  and  strong  until  seven  years  ago,  though  he  was  in  bed  for  some 
time  at  the  age  of  nineteen,  owing  to  stiff  and  painful  knees.  His 
work  had  never  exposed  him  to  lead-poisoning,  as  far  as  he  knew, 
but  for  eighteen  years  he  had  lived  in  a  house  where  drinking-water 
came  through  lead  pipe.  He  denied  venereal  disease;  was  in  the 
habit  of  taking  four  whiskies  a  day. 

Seven  years  ago  he  had  an  attack  of  cramp-like  abdominal  pain, 
accompanying  diarrhea  and  vomiting,  and  lasting  a  week.  During  the 
following  year  he  had  two  or  three  similar  attacks,  and  ever  year  since 
then  he  had  been  disabled  several  times  by  similar  paroxysms.  In 
each  attack  there  was  diarrhea,  followed  by  griping  pain.  He  had 
noticed  no  influence  of  food  in  the  production  of  these  attacks.  For 
the  past  six  months  he  had  been  out  of  work  and  had  so  much  pain 
that  he  had  been  too  discouraged  to  look  for  another  job. 

During  the  past  two  years  he  has  several  times  fallen  in  the  street 
on  account  of  sudden  dizziness,  although  he  has  never  become  un- 
conscious, and  has  been  able  to  get  up  again  without  assistance. 
For  years  he  has  had  pains  of  a  few  seconds'  duration,  off  and  on,  in 
the  muscles  of  the  thigh  and  calf.  On  further  questioning  he  admits 
that  these  sensations  are  not  genuine  pain,  but  rather  a  tingling  and 
numbness.  He  has  no  symptoms  of  bladder  trouble  and  his  eyesight 
is  excellent. 

For  the  above  symptoms  he  was  operated  on  four  months  ago  by 
Dr.  John  C.  Munro,  at  the  Carney  Hospital.  A  few  adhesions  were 
found  and  separated,  but  the  symptoms  continued  as  before.  A  year 
ago  he  was  admitted  to  the  Boston  City  Hospital  for  the  tenth  time, 
and  was  operated  on  by  Dr.  E.  H.  Nichols,  who  did  laminectomy,  ex- 


228 


DIFFERENTL^L  DIAGNOSIS 


posing  the  cord  from  the  second  to  the  sixth  dorsal  vertebrae,  and 
cutting  the  dorsal  nerve-roots  at  the  level  of  the  third,  fourth,  fifth, 
and  sixth  vertebrae,  on  both  sides  of  the  cord.  The  dura  was  edema- 
tous and  considerably  thickened.  He  stated  that  he  experienced  no 
rehef  after  this  operation.  For  the  past  month  he  had  had  some 
cough  and  sputum.  His  best  weight  four  years  ago,  125  pounds; 
at  this  time,  98  pounds.  For  the  past  seven  years  he  had  taken 
morphin,  by  the  mouth,  in  gradually  increasing  amounts,  until  during 
the  last  sbc  months  he  had  needed  18  to  20  gr.  a  day. 

The  patient  was  poorly  nourished  and  pale.     His  pupils  were  cir- 
cular, equal,  reacted  normally  to  distance  and  sluggishly  to  light, 


Fig.  88. — Numb  area  in  Case  86. 

especially  the  right  pupil.  There  was  no  glandular  enlargement. 
His  teeth  were  very  poor.  He  had  a  marked  and  typical  lead-line 
on  the  gums.  Except  for  a  slight  soft  systolic  murmur  at  the  apex, 
the  chest  was  negative,  likewise  the  abdomen.  The  right  knee-jerk 
active;  the  left  present,  but  only  on  reinforcement.  The  right  ankle- 
jerk  likewise  active;  left  not  obtained.  An  area  of  anesthesia  was 
mapped  as  shown  in  Figs.  88,  89.  The  urine  showed  nothing  of 
interest.  Blood-pressure,  130  mm.  Hg.  The  red  cells  showed  slight 
achromia,  and  in  every  few  fields  of  the  oil-immersion  lens  a  stippled 
cell.     The  leukocytes,  13,000.     On  lumbar  puncture  a  limpid  fluid  was 


DIARRHEA 


229 


obtained  in  which  the  white  cells  numbered  74  per  cubic  millimeter, 
99  per  cent,  of  them  being  lymphocytes.  The  fundus  oculi  normal. 
Wassermann  reaction  negative  in  the  blood.  For  a  few  days  he 
excreted  5  to  10  grams  of  sugar  in  the  urine,  and  this  was  still  present 
when  he  left  the  hospital. 

Discussion. — The  history  of  exposure  to  lead-poisoning  through 
drinking-water  makes  it  possible  that  the  abdominal  pain  is  lead- 
colic.  It  is  very  unusual,  however,  for  this  colic  to  be  associated  with 
diarrhea.  Constipation  is  the  rule.  Nothing  in  the  physical  ex- 
amination excludes  lead,  and  there  is  every  reason  to  suppose  that 
part,  at  least,  of  the  patient's  sufferings  are  due  to  this  metal,  since 


Fig.  89. — Numb  area  in  Case 


the  gums  show  its  presence  and  the  blood  examination  strongly 
suggests  the  same  thing. 

Nevertheless,  the  history  of  very  brief  pains  in  the  legs  and  the 
long  intervals  between  the  attacks  of  abdominal  pain  should  suggest 
some  other  disease,  even  in  advance  of  the  physical  examination. 

The  absence  of  the  left  knee-jerk  and  ankle-jerk  and  the  poor 
reaction  of  the  pupils  to  light  prepare  us  for  the  findings  in  the  spinal 
fluid,  which  leave  no  reasonable  doubt  that  the  patient's  abdominal 
attacks  represent  gastric  crises  in  tabes  dorsalis.  But  for  the  examina- 
tion of  the  spinal  fluid,  this  diagnosis  might  not  have  been  clear.  As 
it  is,  the  case  adds  one  to  the  long  list  of  surgical  blunders  due  to  failure 


230  DIFFERENTIAL   DIAGNOSIS 

to  examine  the  nervous  system.  During  the  past  five  years  I  have 
known  5  patients  who,  though  suffering  from  the  gastric  crises  of 
tabes,  were  operated  upon  by  competent  surgeons  in  the  hope  of 
finding  gall-stones,  peptic  ulcer,  or  acute  appendicitis.  Even  after  the 
operation  surgeons  sometimes  fail  to  notice  their  mistake.  A  shriv- 
eled appendix  is  removed  and  the  case  is  called  chronic  appendicitis. 

This  case  also  illustrates  the  proneness  of  surgeons  to  suppose  that 
adhesions  are  a  sufficient  explanation  of  well-marked  clinical  symp- 
toms. A  very  large  number  of  unnecessary  or  mistaken  operations 
fail  to  be  recognized  as  such,  and  are  called  successful  because  a  few 
adhesions  are  found  and  divided.  In  my  experience,  adhesions  in  any 
part  of  the  abdominal  cavity  are  very  seldom,  per  se,  of  any  import- 
ance. 

Had  not  the  evidences  of  tabes  been  found  in  this  case,  one  might 
have  been  forced  to  investigate  the  possibihty  that  the  pain  was  due 
to  morphin.  Morphin  is  a  very  frequent  cause  of  pain,  a  fact  which 
does  not  seem  to  me  sufficiently  realized.  Just  how  the  drug  produces 
pain  I  cannot  say,  but  practically  every  patient  suffering  from  the 
morphin-habit  takes  the  drug  at  times  for  the  relief  of  some  pain,  which 
will  stop  only  when  the  drug  is  ehminated  from  the  system  and  the 
habit  is  broken  up.  I  have  seen  lightning  pains  in  a  tabetic  which 
ceased  as  soon  as  the  morphin-habit,  contracted  for  the  relief  of  these 
same  pains,  was  broken.  In  this  case  one  must  suppose  that  the  pain 
due  to  tabes  itself  had  long  ago  ceased,  its  place  being  taken  by 
suffering  connected  in  some  way  with  the  drug  habit. 

Outcome. — ^As  the  morphin-habit  seemed  to  be  the  most  import- 
ant feature  of  the  patient's  case  at  the  time,  he  was  transferred  on 
April  6th  to  Tewksbury. 

Case  87 

A  housewife  of  forty  entered  the  hospital  April  11,  191 1.  The 
patient  has  been  nervous  all  her  life  and  has  had  stomach  trouble, 
consisting  of  vague  epigastric  distress  after  meals,  never  severe.  Has 
also  had  a  good  many  sick  headaches.  Throughout  her  Ufe  she  has 
had  a  dread  of  crowds,  and  never  goes  to  the  theater  without  a  feeling 
of  great  discomfort.  In  church  she  sits  as  far  back  as  possible.  Dur- 
ing the  past  year  she  has  sometimes  fainted  when  in  crowds. 

She  had  an  Alexander  operation  nine  years  ago,  and  seven  years 
ago  was  operated  upon  for  the  freeing  of  peri-uterine  adhesions. 

For  the  past  year  she  has  had  diarrhea,  gradually  increasing,  until 
now  she  has  six  to  twelve  stools  a  day,  which  are  occasionally  very 


DIARRHEA 


231 


dark,  though  she  is  taking  no  medicine.  Her  fainting  attacks,  for- 
merly rare,  have  now  become  much  more  frequent.  She  consulted  her 
physician  in  November,  19 10,  for  the  above  symptoms,  and  also  on 
account  of  weakness  and  dyspnea.  At  that  time  she  says  that  her 
blood  showed  "marked  secondary  anemia,"  with  a  hemoglobin  of  60 
per  cent.  Under  treatment  she  greatly  improved,  and  hemoglobin 
rose  to  85  per  cent.,  but  in  the  past  few  weeks  her  symptoms  have 


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recurred  and  she  has  vomited  very  frequently.  According  to  her 
statement  she  retains  hardly  any  food.  Three  years  ago  her  weight 
was  138  pounds;  in  November,  1910,  132  pounds;  now,  125  pounds. 

On  physical  examination  she  is  well  nourished,  nervous,  and  ap- 
prehensive. Her  hands  in  constant  motion,  with  some  coarse  tremor. 
Skin,  sclerse,  and  mucous  membranes  of  good  color.  Visceral  examina- 
tion negative.  Reflexes  and  pupils  negative.  Very  sHght  soft  edema 
of  the  ankles.     Urine  normal.     Blood  shows  reds,  2,600,000;  whites. 


232 


DIFFERENTL\L  DIAGNOSIS 


3000;  hemoglobin,  70  per  cent.  During  her  month's  stay  in  the 
hospital  the  course  of  the  red  cells,  white  cells,  and  hemoglobin  was 
as  shown  in  the  accompanying  chart  (Fig.  90).  In  the  stained  smear 
the  red  cells  show  moderate  variations  in  size  and  shape,  no  achromia. 
Occasional  shghtly  abnormal  staming  or  stippling.  No  nucleated 
forms.  Among  the  leukocytes  82  per  cent,  are  lymphocytes,  the  rest 
polynuclears.  This  percentage  does  not  vary  during  her  stay  in  the 
hospital.     Blood-plates  seem  to  be  about  normal  in  number. 

The  stools  were  negative  to  guaiac  and  showed  nothing  else  of 
interest.  The  patient's  tongue  was  unusually  smooth  and  she  had 
frequent  attacks  of  herpetic  stomatitis.  The  range  of  temperature  is 
seen  in  Fig.  91. 


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Discussion. — The  neurotic  taint  in  this  case  is  so  obvious  that  one 
suspects  a  nervous  diarrhea,  but  the  presence  of  blood  in  the  stools 
rules  this  out. 

The  tremor  and  the  sHght  fever  suggests  that  a  thyrotoxicosis 
(Graves'  disease)  may  be  the  cause  of  the  symptoms,  but  the  absence 
of  any  tachycardia,  any  exophthalmos  or  thyroid  enlargement,  and 
the  presence  of  marked  anemia  make  this  very  improbable. 

Cancer  of  the  bowel  would  produce  a  similar  diarrhea  and  anemia, 
but  if  this  diagnosis  were  correct,  one  would  expect  periods  of  pain, 
constipation,  visible  peristalsis,  abdominal  distention,  and  intestinal 


DI>\RRHEA  233 

noise.  The  good  nutrition  of  the  patient  is  further  evidence  against 
the  diagnosis  of  cancer. 

Colitis,  with  or  without  ulceration,  is  very  improbable  in  view  of 
the  negative  condition  of  the  stools.  1 

Pernicious  anemia  is  suggested  by  the  condition  of  the  mouth,  the 
details  of  the  blood-picture,  and  the  tendency  to  periodicity  which  the 
history  portrays. 

Outcome. — She  was  given  two  doses  of  "606,"  the  first,  0.3  gram; 
the  second,  a  week  later,  0.2  gram.  The  diarrhea  ceased  after  the 
second  week,  but  slight  fever  continued  and  the  blood  showed  no 
considerable  improvement.  Nevertheless,  on  the  4th  of  May,  she 
felt  so  comfortable  that  she  decided  to  go  home. 

In  this,  as  in  many  other  cases  of  pernicious  anemia,  sympto- 
matic improvement  occurs,  though  the  blood  remains  unchanged. 
The  effect  of  salvarsan  is  sometimes  much  more  favorable  than  in  this 
case.  Under  its  use,  as  also  under  treatment  by  atoxyl,  some  patients 
improve  very  markedly  not  only  in  their  symptoms,  but  in  their  blood- 
picture.  Arsenic,  given  in  the  form  of  Fowler's  solution,  may  be  less 
effective  than  when  it  is  taken  as  salvarsan  or  atoxyl.  It  must  be 
recognized,  however,  that  no  known  form  of  treatment,  whether  by 
arsenic  or  by  the  recently  much-heralded  thorium,  or  by  splenectomy, 
does  anything  more  than  retard  for  a  few  months  the  fatal  termina- 
tion of  the  disease. 

This  patient  died  on  the  6th  of  June,  191 1. 

Case  88 

A  banker  of  thirty-six  entered  the  hospital  July  14,  191 1.  The  pa- 
tient's father  died  of  ''anemia"  at  sixty-six;  otherwise  family  history  is 
excellent  and  past  history  negative,  except  that  he  has  had  ever  since 
twelve  years  of  age  a  good  many  attacks  of  abdominal  pain  and  diar- 
rhea. Two  years  ago  he  weighed  145  pounds  and  felt  reasonably  well, 
when  he  was  attacked  by  a  severe  diarrhea  and  was  in  bed  three  weeks. 
Since  then  he  has  never  been  really  vigorous.  Most  of  last  summer 
he  was  in  bed  in  a  hospital  and  gained  somewhat,  but  every  few  weeks 
he  has  attacks  of  pain  and  diarrhea,  the  pain  being  at  times  very  severe, 
but  never  locaUzed.  He  rarely  vomits,  but  several  times  has  had 
slight  jaundice.  Tenesmus  has  been  a  troublesome  sjrmptom.  Since 
January  of  this  year  it  has  been  noticed  that  he  is  paler  than  usual. 
His  best  weight,  145  pounds,  was  maintained  up  to  two  years  ago, 
since  when  he  has  gradually  fallen  to  120  pounds.  He  worked  until 
the  28th  of  June. 


234 


DIFFERENTL\L  DIAGNOSIS 


On  physical  examination  he  is  rather  sallow,  mucous  membranes 
pale.  A  soft  systoUc  murmur  replaces  the  first  heart  sound  all  over 
the  precordia.  The  aortic  second  sound  is  faint.  Abdomen  shows  a 
marked  visible  pulsation  in  the  epigastrium,  and  some  tenderness  with 
shght  rigidity,  most  notable  in  the  region  of  the  gall-bladder.  Visceral 
examination  and  the  reflexes  otherwise  normal.  Proctoscopic  ex- 
amination shows  nothing  abnormal  in  the 
lower  8  inches  of  the  bowel.  The  stools 
are  negative  to  guaiac  and  show  no  other 
abnormahties.  A  specimen  of  urine, 
taken  under  aseptic  precautions,  shows 
moderate  growth  of  streptococci.  Tem- 
perature ranges  as  seen  in  the  accom- 
panying chart  (Fig.  92). 

The  blood  shows  red  cells,  1,500,000; 
white  cells,  3000;  hemoglobin,  40  per 
cent.  In  the  stained  smear  the  red  cells 
show  marked  variations  in  size  and  shape, 
with  many  huge  oval  forms.  One  megalo- 
blast  and  one  normoblast  are  seen  while 
counting  200  leukocytes,  among  which  65 
per  cent,  are  lymphocytes;  the  rest,  poly- 
nuclears.  A  few  stippled  forms  and 
many  abnormal  staining  reactions  were 
found.  The  urine  is  negative. 
Discussion. — The  history  of  this  case  gives  no  distinct  clue  to  its 
nature.  The  abdominal  pulsation  might  bring  aneurysm  into  con- 
sideration. The  absence  of  pain  in  the  back,  of  any  definite  tumor, 
and  the  central  position  of  the  pulsation  (that  of  aneurysm  is  usually 
to  one  side  of  the  median  line)  make  this  very  improbable.  More- 
over, with  such  an  anemia  as  is  here  present,  unusual  pulsations  of 
one  or  another  artery  are  very  common.  Indeed,  they  have  often 
been  mistaken  for  aneurysms,  as  in  the  case  reported  by  Dr.  A.  R. 
Edwards,  in  the  "Transactions  of  the  Association  of  American  Physi- 
cians," for  the  year  1902. 

The  presence  of  streptococci  in  the  urine  points  to  a  mild  degree 
of  urinary  sepsis.  In  the  absence  of  pus,  this  finding  is  probably  not 
of  great  importance.  It  certainly  cannot  be  responsible  for  so  marked 
an  anemia. 

The  epigastric  tenderness  and  rigidity,  taken  in  connection  with 
the  evidence  of  a  severe  anemia,  bring  cancer  of  the  stomach  into 


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DIARRHEA  235 

consideration,  but  the  history  of  two  years'  illness,  the  rarity  of 
vomiting,  and  the  gradual  and  only  moderate  loss  of  weight  are 
against  this  idea. 

The  details  of  the  blood-picture,  with  the  negative  results  of 
physical  examination  and  of  :r-ray  examination,  point  straight  to 
pernicious  anemia. 

Outcome. — On  the  17th  the  edge  of  the  spleen  was  felt.  After 
the  i8th  the  gastric  symptoms  were  very  slight.  The  appetite  gener- 
ally good.  Bismuth  x-ray  examinations  showed  that  a  considerable 
amount  of  bismuth  remained  in  the  stomach  an  hour  after  ingestion, 
but  no  intestinal  lesion  and  no  obstruction  of  the  pylorus  was  made 
out.  Stasis  of  this  degree  has  been  noted  in  several  of  our  cases  of 
pernicious  anemia,  proved  by  autopsy  to  be  such. 

The  patient  went  home,  without  any  change  in  his  condition,  July 
2ist.  He  improved  somewhat  after  this,  and  about  the  ist  of  January, 
191 2,  was  much  better,  but  in  April  he  began  to  run  down  again,  and 
on  the  15th  of  May  he  died. 

Case  89 

A  housewife  of  forty-seven  entered  the  hospital  October  6,  191 1. 
The  patient's  mother  died  at  sixty-one  of  a  "growth  in  the  liver." 
One  brother  died  of  consumption  at  twenty- three.  The  patient  has 
had  no  serious  illness,  but  has  always  been  very  nervous  and  lacked 
vitality.  Since  the  menopause,  two  years  ago,  she  has  had  "nervous 
prostration  and  neurasthenia"  many  times.  A  year  ago  she  had 
"acute  indigestion,"  and  since  then  has  suffered  constantly  from  sour 
stomach.  For  the  past  few  months  she  has  vomited  sour  material  a 
good  many  times.  She  says  her  pain  is  due  to  hydrochloric  acid 
trickling  about  the  abdominal  interstices  and  coming  up  into  her 
throat  in  burning  waves.     She  has  never  vomited  blood. 

One  week  ago  she  began  to  have  severe  diarrhea,  and  her  ab- 
domen, previously  "small  and  shriveled,"  began  to  be  distended. 
With  this  change  came  cramp-like  pain  and  constant  soreness  in  the 
lower  abdomen. 

Since  her  stomach  trouble  began  a  year  ago  her  legs  have  been 
swollen  and  have  felt  very  heavy  at  times.  This  has  been  especially 
marked  in  the  last  two  weeks.  A  year  ago  she  weighed  135  pounds, 
with  clothes,  but  she  has  lost  much  weight  since,  and  for  the  past  year 
has  done  but  Httle  housework  and  has  been  recumbent  most  of  the 
time,  though  lying  down  often  increases  her  abdominal  pain. 

On  physical  examination  the  patient  was  found  to  be  emaciated 


236  DIFFERENTLA.L   DIAGNOSIS 

and  so  weak  that  she  spoke  with  difficulty.  Pupils  and  reflexes  nega- 
tive. Tongue  dry  and  cracked.  Left  border  of  cardiac  dulness  was 
3  cm.  outside  the  nipple  line.  The  apex  impulse  could  be  seen  and 
felt  indistinctly  almost  as  far  as  the  anterior  axillary  line.  The 
sounds  were  of  good  quality,  the  action  regular,  the  first  apex  sound 
loud,  accompanied  by  a  slight  systolic  murmur.  The  aortic  second 
and  pulmonic  second  sounds  were  of  equal  intensity.  The  pulses 
were  equal  and  normal  in  volume  and  tension.  Artery  walls  not  felt. 
Lungs  negative. 

Abdomen  moderately  distended;  it  showed  dulness  in  the  flanks, 
shifting  with  change  of  position;  also  a  fluid  wave.  The  vaginal  walls 
seemed  to  be  pushed  together  by  masses  of  considerable  hardness, 
apparently  outside  the  vault.  The  cervix  uteri  was  normal,  the 
fundus  not  made  out.  The  rectum,  like  the  vagina,  seemed  to  be 
enlarged  by  external  pressure,  but  both  examinations  were  unsatis- 
factory because  of  pain. 

There  was  marked  soft  edema  below  the  knees.  The  patient 
vomited  almost  everything  and  could  not  hold  fluid  by  rectum. 
The  stools  were  small  and  consisted  largely  of  liquid  and  mucus. 
Operation  was  considered,  but  discouraged. 

Discussion. — Although  this  patient  has  been  supposed  to  have 
nervous  prostration,  the  fact  that  her  troubles  began  after  forty 
makes  this  improbable. 

Stomach  symptoms  beginning  at  her  age  and  followed  by  swelling 
of  the  legs,  even  in  recumbency,  make  a  very  ominous  combination 
of  symptoms.  It  suggests  gastric  cancer  followed  by  peritoneal 
metastases.  The  dropsy  is  not  at  all  easy  to  explain  on  the  ground 
of  any  cardiac  disease,  for  although  the  heart  shows  evidences  of  en- 
largement and  of  weakness,  the  dropsical  fluid  seems  to  be  confined  to 
the  abdomen  and  legs,  the  lungs  remaining  clear.  The  finding  of 
pelvic  masses  went  to  confirm  the  diagnosis  suggested  above. 

Outcome. — The  patient  died  October  15th.  Autopsy  showed  a 
gastric  cancer  of  the  "fibromatous"  infiltrating  type,  extending  not 
only  throughout  the  stomach,  but  over  a  considerable  part  of  the  large 
intestine  in  the  form  of  a  tough,  whitish  membrane,  resembling  that 
of  chronic  peritonitis,  also  spreading  along  the  peritoneal  surface 
from  the  stomach  by  contiguity.  The  stomach  was  not  enlarged, 
showed  no  tumor,  no  ulceration,  and  no  pyloric  obstruction.  The 
pelvis  was  wholly  clear  and  showed  no  glandular  metastases.  One 
ureter  was  blocked  by  a  cancerous  membrane  and  a  hydronephrosis 
had  resulted  on  that  side.     The  other  kidney  showed  suppurative 


DIARRHEA  237 

nephritis.  The  cancerous  growth  along  the  large  intestine  had 
resulted  in  numerous  carcinomatous  strictures.  There  were  also 
some  cancerous  nodules  in  the  right  kidney  and  in  certain  perito- 
neal lymphnodes. 

The  heart  showed  a  well-marked  mitral  stenosis,  though  the 
organ  weighed  only  212  grams.     Moderate  ascites  was  present. 

Case  90 

A  French  Canadian  barber  of  forty-four  entered  the  hospital  Sep- 
tember 26,  191 1.  For  years,  he  says,  his  bowels  have  moved  three  or 
four  times  a  day,  usually  in  the  morning,  but  several  times  more 
later  in  the  day  if  he  drinks  cold  water.  He  has  noticed  nothing  re- 
markable about  the  movements  and  has  had  no  tenesmus.  He 
thinks  he  has-  lost  about  15  pounds  in  the  past  year.  Liquid  diet, 
especially  milk,  makes  his  diarrhea  worse.  On  a  diet  of  meat  alone  he 
has  only  one  or  two  movements  a  day. 

Eighteen  days  ago  he  got  a  cold  in  his  head,  felt  chilly,  and  had 
vague  pains  in  his  legs  and  back.  These  symptoms  have  continued 
since.  A  nasal  discharge  is  very  profuse  in  the  morning,  sometimes 
slightly  blood  tinged.  A  frontal  headache,  more  marked  on  the  left 
side,  has  been  present  from  the  beginning  of  his  cold.  It  begins  in 
the  morning,  before  he  gets  up,  and  wears  away  toward  night.  His 
nose,  cheek-bones,  and  bones  behind  his  ears  are  sore.  He  has  had 
some  cough  for  eighteen  days  and  raises  a  little  thick,  yellow  sputum. 
Appetite  is  very  poor,  and  he  has  spells  of  retching  every  morning 
since  the  cold  came  on. 

Physical  examination  shows  poor  nutrition,  moderate  pallor. 
Pupils  slightly  irregular,  equal,  reacting  sluggishly.  The  glands  on 
the  left  side  of  the  neck  are  slightly  enlarged  and  tender.  Both 
epitrochlears  are  palpable;  they  are  about  the  size  of  small  beans. 
The  throat  shows  a  dry,  chronic  pharyngitis.  The  first  heart  sound  is 
short  and  feeble,  otherwise  the  heart  shows  nothing  abnormal.  The 
radials  are  moderately  thickened  and  tortuous.  Blood-pressure, 
systolic,  150  mm.  Hg.;  diastolic,  no  mm.  Hg.  Physiologic  pecuKari- 
ties  of  the  right  pulmonary  apex  seem  somewhat  exaggerated.  A  few 
tortuous  dilated  veins  are  seen  over  the  abdomen,  which  is  otherwise 
negative.  The  reflexes  are  normal.  There  is  moderate  tenderness 
over  the  left  eyebrow,  none  over  the  right.  Mastoid  and  cheek-bones 
not  tender.  White  corpuscles,  13,800,  with  a  normal  differential 
count.  Urine  averages  45  ounces  in  twenty-four  hours,  a  few  hyaline 
or  granular  casts.     The  range  of  the  temperature  is  seen  in  the  ac- 


238 


DIFFERENTIAL  DIAGNOSIS 


companying  chart  (Fig.  93).  Examination  by  Dr.  Algernon  Coolidge 
showed  acute  frontal  sinusitis,  in  the  stage  of  recovery,  and  chronic 
atrophic  rhinitis.  Rectal  examination  showed  that  the  sphincter 
admitted  the  tip,  of  the  finger  only. 

Discussion. — The  long  duration  of  the  intestinal  symptoms  in 
this  case  makes  it  natural  to  speculate  whether  the  patient  is  not 
one  of  those  persons  who  habitually  have  several  movements  of  the 
bowel  each  day  while  in  full  health.  The  loss  of  15  pounds  in  weight 
within  a  year,  however,  makes  this  supposition  improbable. 

From  the  history  alone  no  diagnosis 
is  possible  in  this  case.  The  most 
definite  points  are  the  loss  of  weight 
and  the  presence  of  some  infection  of 
the  upper  air-passages  and  facial  bone- 
cavities.  The  presence  of  a  rectal  stric- 
ture is  a  much  more  enlightening  datum, 
and  suggests  at  once  the  possibility  of 
syphilis.  This  is  further  strengthened 
by  the  irregularity  and  sluggishness  of 
the  pupils,  by  the  general  glandular  en- 
largement, the  premature  sclerosis  of  the 
arteries,  and  the  slight  elevation  of  blood- 
pressure. 

Outcome. — All  attempts  to  penetrate 
further  into  the  rectum  were  prevented  by 
pain.  Dr.  Daniel  F.  Jones  believed  this 
sphincter  to  be  of  syphilitic  origin  and 
advised  gradual  dilatation  with  bougies. 
Wassermann  reaction  was  negative.  Mercurial  inunctions  and  iodid 
of  potash  were  given  during  his  stay  in  the  hospital.  Diarrhea  soon 
ceased  and  the  frontal  sinus  cleared  up. 


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Fig.  93. — Chart  of  Case  90. 


Case  91 

A  freight  conductor  of  twenty-seven  entered  the  hospital  October 
27,  191 1,  complaining  of  a  diarrhea  of  eight  days'  duration.  His 
mother  died  of  inflammation  of  the  bowels.  His  wife  was  then  under 
treatment  for  syphilis.  Wassermann  reaction  positive.  One  child, 
aged  three  and  a  half  years,  had  iritis  and  was  also  under  treatment. 
One  child  died,  at  two  months,  of  syphilis.  The  patient  himself  had 
a  hard  chancre  six  years  ago,  but  no  other  symptoms,  and  had  con- 
sidered himself  entirely  well  until  of  late.     In  this  attack  he  had  been 


DIAREHEA 


239 


aware  of  headache  and  fever  since  the  second  day  and  had  felt  in- 
creasingly weak,  but  kept  at  work  until  two  days  before.  Since 
that  he  had  stayed  at  home,  but  had  not  remained  in  bed. 


Physical  examination  showed  good  nutrition.  Nothing  abnormal 
in  the  internal  viscera.  Blood-pressure,  no  mm.  Hg.  Temperature 
as  in  the  accompanying  chart  (Fig.  94).  Urine  normal.  White 
corpuscles,  8000.    Widal  reaction  negative. 


240  DIFFERENTIAL   DIAGNOSIS 

Discussion. — Here  we  have  an  obvious  s)^hilitic  history  in  the 
patient  and  his  family.  In  this  infection  diarrhea  may  result  either 
as  a  part  of  the  general  intoxication  or  from  a  stricture  of  the  rectum, 
with  irritation  of  the  bowel  above  it  from  retained  feces.  But  for  the 
blood-culture,  mentioned  below,  it  certainly  would  have  been  im- 
possible to  make  a  diagnosis  of  this  patient's  trouble  on  the  27  th  of 
October.  When  one  looks  at  the  chart  and  takes  it  in  connection 
with  a  physical  examination,  which  enables  us  to  exclude  tuberculosis 
and  sepsis  with  considerable  probability,  typhoid  fever  becomes  prob- 
able, even  in  view  of  the  negative  Widal  reaction. 

Outcome. — Blood-culture,  October  28th,  was  positive  for  typhoid 
bacilli.  Widal  reaction  did  not  become  positive  until  November  9th. 
White  corpuscles  ranged  at  their  highest  to  10,000,  November  23d. 
Five  days  before  this  he  had  a  moderate-sized  intestinal  hemorrhage, 
which  was  treated  by  starvation  and  morphin.  The  course  of  his  dis- 
ease was  otherwise  uneventful,  and  he  left  the  hospital  in  good  condi- 
tion January  4,  191 2. 

Case  92 

An  unmarried  woman  of  twenty-eight,  living  at  home,  entered 
the  hospital  December  2,  191 1.  Her  family  history  and  past  history 
were  not  remarkable.  Until  six  years  ago,  when  she  had  the  measles 
and  was  sick  for  four  weeks,  she  was  well,  but  since  that  time  she  says 
that  "her  stomach  has  never  been  right."  Her  bowels  have  moved 
from  two  to  five  times  a  day,  and  four  times  she  has  noticed  a  small 
amount  of  fresh  blood  in  the  movements.  She  has  distress  after  her 
meals  and  belches  much  gas  and  sour  material.  She  has  no  vomiting 
and  no  sharp  or  localized  pain.  Her  discomfort  is  sometimes  relieved 
by  hot  drinks.  Her  weight  four  months  ago  was  128  pounds;  three 
weeks  ago,  112  pounds.  She  has  worked  during  the  whole  of  her 
illness  except  for  a  vacation  of  three  weeks  in  July. 

On  examination  the  patient  was  well  nourished.  Chest  negative. 
Abdomen  showed  slight  diffuse  tenderness  and  a  firm,  slightly  tender 
sausage-shaped  tumor  in  each  lower  quadrant.  There  was  no  spasm, 
but  much  intestinal  noise.  The  right  kidney  easily  palpable.  Blood- 
pressure,  no  mm.  Hg.  Blood  and  urine  normal.  A  stool  showed 
no  food  residue  to  the  naked  eye,  but  under  the  microscope  much 
undigested  food  was  seen,  with  considerable  mucus  and  a  positive 
guaiac  test.  Bacteriologic  examination  of  the  stools  showed  nothing 
remarkable.  She  remained  three  weeks  in  the  ward  and  gained  6 
pounds.     Tube  examination  of  the  stomach  showed  nothing  wrong, 


DIARRHEA  241 

except  that  hydrochloric  acid  was  absent  on  one  occasion.  After  the 
loth  of  December  her  bowels  moved  regularly  and  her  appetite  was 
fair.  The  epigastric  soreness  and  tenderness  persisted.  She  left  the 
hospital  December  24th. 

Discussion. — There  is  nothing  in  this  case  to  indicate  organic 
disease.  The  sausage-shaped  tumors  are  probably  fecal.  Her  diar- 
rhea is  probably  the  expression  of  poor  general  condition.  The  pres- 
ence of  undigested  food,  under  the  microscope,  is  of  no  special  im- 
portance, in  view  of  the  repeated  disappearance  of  her  diarrhea  under 
no  special  treatment  except  rest.  In  many  cases  of  this  type  it  turns 
out  that  diarrhea  is  dependent  upon  constipation  and  the  irritation 
produced  by  this.  Many  of  these  cases  have  pain  and  pass  mucus, 
so  that  the  term  "mucous  colitis"  is  applied  to  them,  but  the  distinc- 
tion between  this  type  of  disease  and  ordinary  constipation  is  by  no 
means  a  sharp  one,  especially  when  the  trouble  occurs  in  high-stnmg 
women. 

Outcome. — The  patient  has  been  followed  by  Drs.  H.  F.  Hewes 
and  John  W.  Dewis  since  leaving  the  hospital.  The  former  con- 
sidered the  case  one  of  functional  diarrhea,  with  incapacity  to  take 
care  of  fats.  When  she  rests  the  diarrhea  ceases.  When  she  gets 
tired,  it  recurs  and  lasts  a  month  or  so.  I  agree  with  Dr.  Hewes' 
diagnosis. 

January  12,  191 2,  Dr.  Scudder  operated,  removed  an  appendix, 
and  severed  some  adhesions  about  the  ascending  colon.  There  were 
also  adhesions  extending  from  the  duodenum  to  the  gall-bladder  and 
some  indications  of  a  Lane's  kink.  There  was  no  evidence  of  gall- 
stones. The  stomach  and  pancreas  were  also  explored  through  the 
epigastric  incision  and  nothing  found. 

Through  the  summer  of  191 2  she  was  under  the  care  of  Dr.  John 
W.  Dewis.  In  August  the  hemoglobin  was  75  per  cent.,  and  a  stained 
specimen  showed  moderate  achromia.  Physical  examination  and 
examination  of  the  stomach  contents  and  feces  showed  nothing  ab- 
normal. November  13,  191 2,  she  reported,  saying  that  she  was 
doing  excellently  and  feeling  like  her  old  self.  The  blood  was  then 
normal. 

Case  93 

A  cigarmaker  of  forty- two  entered  the  hospital  March  17,  191 2. 
Family  history  and  past  history  are  negative  except  that  one  sister 
died  of  cancer,  situation  unknown.  Four  weeks  ago  he  began  to  have 
a  bloody  dysentery.     He  had  committed  no  indiscretion  in  diet  and 

Vol.  11—16 


242  DIFFERENTIAL   DIAGNOISS 

there  were  no  similar  cases  at  his  boarding-house.  The  day  after  the 
onset  of  this  trouble  he  took  to  bed  and  has  been  there  ever  since, 
suffering  from  slight  fever  with  pains  in  his  arms,  legs,  and  throat. 
For  the  last  two  weeks  he  has  had  headache,  increasing  mental  con- 
fusion, and  loss  of  memory.  His  diarrhea  has  now  ceased  and  his 
bowels  are  moving  daily  with  laxatives. 

The  predominating  symptoms  at  entrance  are  cerebral.  Drowsi- 
ness, slowness  in  answering  questions,  and  aphasia  are  marked.  He 
appears  to  have  forgotten  many  important  events  of  his  life  and  has 
no  clear  idea  of  his  present  illness.  He  would  often  stop  in  the  middle 
of  a  sentence,  yet  show  no  consciousness  that  he  had  stopped.  Occa- 
sionally he  stuttered  or  slurred  over  words. 

Physical  examination  shows  exaggeration  of  the  knee-,  elbow-,  and 
wrist-jerks.  No  ankle-clonus  or  Babinski.  The  patient's  move- 
ments seem  slightly  unsteady,  but  he  can  write  and  pick  up  objects 
without  difl&culty.  Physical  examination  is  otherwise  quite  negative. 
The  urine  is  negative.  Blood-pressure,  140  mm.  Hg.  Wassermann 
reaction  negative.  Stools  negative.  The  blood  shows  19,000  leuko- 
cytes, March  17th,  with  90  per  cent,  hemoglobin.  Among  the  white 
cells  there  are  polynuclears,  43  per  cent.;  lymphocytes,  30  per  cent.; 
eosinophils,  27  per  cent.  March  21st  the  leukocytes  are  27,500, 
with  polynuclears,  37  per  cent.;  lymphocytes,  23  per  cent.;  eosinophils, 
39  per  cent.     Mast-cells,  i  per  cent. 

On  the  day  after  entrance  a  marked  injection  of  the  conjunctivae 
and  slight  edema  under  the  eyes  were  noticed.  This,  with  the  eosino- 
philia,  led  to  an  examination  of  a  bit  of  calf  muscle,  where  trichinae 
were  found.  Within  a  week  the  mental  symptoms  wholly  cleared  up 
and  the  man  seemed  entirely  normal.  At  no  time  was  there  any  marked 
muscular  soreness,  but  Dr.  Henry  Jackson,  who  had  seen  him  pre- 
vious to  his  entrance  to  the  hospital,  reported  that  he  had  been  eating 
poorly  cooked  sausages  before  the  onset  of  the  present  attack. 

Discussion. — The  mental  symptoms  which  were  so  prominent 
in  the  clinical  picture  of  this  patient's  illness  would  naturally  sug- 
gest arteriosclerosis  or  dementia  paralytica.  As  his  diarrhea  had 
ceased  before  he  came  under  observation,  his  only  symptoms,  beyond 
the  psychosis  just  mentioned,  were  headache,  slight  fever,  and  gener- 
alized pains. 

With  these  data  only  and  without  the  routine  blood  examination, 
which  has  been  long  one  of  our  most  valuable  safeguards  against  errors 
of  diagnosis,  this  case  certainly  could  not  have  been  unraveled,  but 
the  eosinophilia,  once  discovered,  has  enormous  importance  in  this 


DIARRHEA  243 

case  because  most  of  the  causes  for  that  symptom  (causes  such  as 
intestinal  parasites,  chronic  skin  diseases,  and  anaphylactic  reactions) 
can  be  easily  excluded.     This  done,  trichiniasis  is  at  once  suggested. 


Case  94 

A  clothing  salesman  of  thirty-one,  born  in  Russia,  entered  the 
hospital  June  3,  191 2.  He  has  been  troubled  for  four  weeks  with 
diarrhea,  severe  in  the  last  four  or  five  days,  with  noticeable  loss  of 
weight  and  strength.  These  are  the  patient's  chief  complaints.  At 
present  he  has  twelve  or  more  movements  daily,  consisting  of  mucus, 
blood,  and  watery  fluid.  Preceding  each  stool  there  is  cramp-like 
pain  in  the  lower  abdomen.  At  other  times  no  pain.  The  appetite  is 
fair,  but  he  frequently  has  slight  epigastric  discomfort  an  hour  after 
meals.  Has  noticed  sHght  dyspnea  on  exertion  and  some  swelling 
of  the  ankles.  Four  months  ago  his  weight  was  155  pounds,  with 
clothes;  June  12th  it  was  129  pounds,  without  clothes. 

Physical  examination  shows  fair  nutrition.  Negative  pupils  and 
reflexes.  Chest  negative.  In  the  abdomen  nothing  of  interest  except 
a  sausage-shaped  mass  in  the  left  lower  quadrant. 

Microscopically  the  stools  show  mucus,  blood,  epithelial  cells, 
and  leukocytes,  with  very  little  fecal  matter.  The  sigmoidoscope 
show^s  that  the  mucous  membrane  of  the  rectum  and  sigmoid,  as  far 
up  as  visible,  is  red  and  covered  with  numerous  minute  ulcerations  and 
blood-clots.  It  is  subsequently  learned  that  the  patient  spent  six 
weeks  in  Rutland,  at  a  boarding-house  for  tuberculosis,  but  was  not 
in  the  sanitarium.  This  was  six  years  ago,  following  a  cough  which 
had  lasted  twelve  weeks. 

The  patient's  blood  and  urine  are  not  remarkable  except  that 
the  blood-smear  shows  6  per  cent,  of  eosinophils.  The  Wassermann 
reaction  is  negative.  Culture  from  the  stools  shows  the  gas  bacillus. 
A  pint  of  5  per  cent,  silver  nitrate  solution  is  injected  June  5  th  and 
9th,  but  is  held  only  a  minute  and  produces  no  improvement. 

Discussion. — The  presence  of  6  per  cent,  eosinophils  in  this 
patient's  blood  suggests  that  the  diarrhea  may  be  due  to  some  intes- 
tinal parasite,  but  the  examination  of  the  stools  showed  no  such 
parasite  and  the  eosinophilia  remained  unexplained. 

The  history  of  a  residence  at  a  health  resort  for  tuberculosis, 
after  a  cough  which  lasted  twelve  weeks,  makes  it  necessary  to  con- 
sider tuberculosis  of  the  bowel,  but  the  fact  that  six  years  have  elapsed 
since  the  patient  has  had  any  pulmonary  symptoms,  and  that  his 


244  DIFFERENTIAL  DIAGNOSIS 

lungs  are  now  normal,  makes  it  unlikely  that  tuberculosis  now  exists 
in  the  bowel. 

Direct  inspection  of  the  bowel  proves  the  presence  of  an  ulcera- 
tive colitis,  the  causal  agent  unknown.  There  is  no  good  reason  for 
connecting  the  presence  of  a  gas  bacillus  with  the  diarrhea.  Cases 
of  this  type  represent  an  unexplored  country  in  medicine.  We  know 
nothing  of  their  cause  and  but  Httle  of  their  prognosis  and  treatment. 

Outcome. — June  12  th  he  left  the  hospital  unimproved.  On  the 
2  2d  of  June  Dr.  Daniel  F.  Jones  opened  the  bowel  at  the  cecum,  pro- 
ducing an  artificial  anus,  and  instituted  regular  washings  of  the  colon 
with  normal  saline  solution,  injected  through  the  artificial  opening, 
twice  daily.  This  was  kept  up  until  the  25  th  of  August.  By  that 
time  the  opening  had  closed  so  that  no  feces  escaped,  yet  it  was  suffi- 
ciently open  to  permit  the  colonic  washes  to  be  continued.  He  went 
to  work  again  in  October,  and  by  December  5th  had  gained  25  pounds 
and  was  still  free  from  diarrhea,  though  his  movements  occasionally 
contained  a  little  blood.  Later  he  relapsed,  and  on  May  22,  19 14, 
reported  that  he  was  in  about  the  same  condition  as  when  he  first 
entered  the  hospital. 

Case  95 

A  mechanic  of  thirty-four  entered  the  hospital  May  17,  191 2. 
The  patient's  family  history  was  negative.  Fourteen  years  ago  he 
had  a  chancre  and  a  bubo.  Was  treated  by  an  army  doctor.  While 
in  the  Philippines  in  1899  he  had  mountain  fever  and  was  sick  for  ten 
days.  Otherwise  he  had  been  well  until  the  present  illness.  In  the 
autumn  of  1909,  while  in  Georgia  with  Buffalo  Bill's  show,  he  began 
to  have  diarrhea,  the  stools  preceded  by  severe  cramps,  and  con- 
sisting of  mucus  and  dark,  clotted  blood.  In  the  following  winter 
he  was  for  three  months  in  St.  John's  Hospital  in  Brooklyn,  New  York. 
The  next  spring  he  was  able  to  do  heavy  work  and  has  kept  at  it  ever 
since,  though  having  occasional  cramps  and  one  or  two  loose  stools 
daily.     He  has  eaten  no  meat,  potato,  cabbage,  peas,  or  corn. 

Nine  months  before  entry  his  diarrhea  recurred,  and  three  months 
before  he  gave  up  work.  For  the  past  six  weeks  he  had  had  twelve 
to  eighteen  stools  a  day  and  a  constant  burning  pain  in  the  abdomen. 
His  appetite  was  good,  but  if  he  ate  as  much  as  he  desired  he  had  to 
vomit,  though  the  vomiting  was  not  preceded  by  nausea.  Four  years 
ago  he  weighed  180  pounds;  six  months  ago,  169  pounds,  in  his  clothes; 
at  this  time,  145^  pounds,  without  clothes. 

Physical  examination  shows  slight  tenderness  along  the  colon  on 


DIARRHEA  245 

the  right  side  of  the  abdomen.  Otherwise  the  internal  viscera  are 
negative.  The  blood  showed  29,000  leukocytes,  with  a  polynucleosis 
at  the  time  of  entrance.  Four  days  later,  leukocytes,  16,500.  The 
urine  was  negative.  The  stools  showed  many  ameba;  in  active  mo- 
tion, some  of  them  containing  numerous  included  red  corpuscles. 

Discussion  .^ — Repeated  and  prolonged  attacks  of  diarrhea  in  a 
patient  who  has  lived  in  the  tropics  are  strong  presumptive  evidence 
of  amebic  dysentery.  A  careful  study  of  the  characteristics  of  the 
amebae  found  in  the  stools  dispelled  all  doubt  of  the  diagnosis.  The 
case  is  detailed  here  chiefly  on  account  of  the  treatment  followed. 

Outcome. — The  patient  was  given  quinin  injections,  with  some 
relief,  but  May  20th  the  following  treatment  was  substituted:  The 
patient  received  no  food  except  broth  after  1 2  noon  of  the  first  day  of 
treatment.  At  6  p.  m.  he  was  given  40  gr.  of  ipecac  in  5-gr.  capsules 
coated  with  keratin.  Each  night,  after  a  similar  half-day's  starvation, 
the  patient  was  given  ipecac,  the  dose  being  reduced  5  gr.  each  day 
until  a  dose  of  10  gr.  was  reached.  The  latter  then  continued  each  night. 
The  patient  bore  this  treatment  excellently  well.  Pain  during  bowel 
movements  stopped  within  a  few  days,  the  first  relief,  he  says,  since 
the  onset  of  his  trouble.  The  bowel  movements  at  first  became  very 
watery,  several  large  evacuations  taking  place  during  the  night  and 
the  day.  By  May  30th  he  had  only  one  or  two  movements  in  twenty- 
four  hours.  The  feces  were  formed  and  amebse  could  no  longer  be 
found.  Several  of  the  large  doses  of  ipecac  caused  nausea  and  shght 
watery  vomiting  three  hours  after  taking,  but  only  once  was  the 
medicine  vomited  (the  2 5-gr.  dose).  On  the  31st  he  left  the  hospital, 
preferring  to  finish  up  treatment  at  home. 

Now  that  we  have  the  emetin  treatment,  introduced  soon  after 
this  date  by  Rogers,  we  need  no  longer  struggle  against  the  difficul- 
ties of  administering  ipecac. 

Case  96 

A  conductor  of  thirty,  born  in  Austria,  here  thirteen  years,  entered 
the  hospital  March  30,  191 2.  For  two  years,  without  known  cause, 
he  had  been  having  diarrhea  with  a  few  intervals  of  comparative 
freedom.  His  family  and  past  history  negative.  The  stools  were 
three  to  twelve  a  day  and  preceded  by  cramps.  Until  two  weeks  ago 
his  appetite  had  been  good.  He  had  had  no  vomiting  or  other  symp- 
toms. Three  years  ago  he  weighed  198  pounds,  with  clothes;  now 
149  pounds,  without  clothes.     His  bowels  never  move  at  night. 

On  physical  examination  he  was  not  emaciated,  muscular,  but  looked 


246  DIFFERENTIAL    DIAGNOSIS 

worried.  Visceral  examination,  together  with  the  blood  and  urine, 
temperature,  pulse  and  respiration,  showed  nothing  abnormal.  Proc- 
toscopic examination  in  the  Out-patient  Department  was  negative. 
The  stools  showed  no  blood  or  pus  or  food  residue,  and  were  always 
negative  to  guaiac.  During  a  week's  stay  in  the  hospital  the  patient 
had  but  one  movement  daily  while  under  treatment  by  buttermilk, 
and  a  diet  consisting  of  eggs,  fish,  and  meat,  with  one  slice  of  toast 
three  times  a  day.  Toward  the  end  of  his  stay  he  was  so  constipated 
he  had  to  receive  laxatives. 

Discussion. — Of  special  importance  seems  to  me  the  fact  that  this 
man's  bowels  never  move  at  night.  I  have  never  known  a  case  of 
diarrhea  due  to  ulcerative  enteritis  in  a  patient  whose  bowels  move 
only  in  the  daytime.  Moreover,  the  examination  of  the  stools  has 
never  shown  evidence  of  intestinal  ulceration,  and  the  patient's  weight 
has  been  steadily  though  rather  slowly  increasing.  The  case  remains 
a  somewhat  mysterious  one,  as  it  is  difficult  to  conceive  that  psychic 
causes  or  mere  habit  can  be  responsible  for  so  long  a  trouble  in  a  pa- 
tient of  this  type  and  temperament.  He  shows  no  evidence  of  a  ner- 
vous make-up. 

Outcome. — For  two  weeks  after  leaving  the  hospital  the  patient 
was  free  from  diarrhea,  then  it  returned,  and  by  the  24th  of  April 
was  worse  than  ever.  He  followed  the  diet  closely,  but  without  good 
result.  There  has  been  no  soreness  of  the  mouth.  The  stool  ex- 
amined at  that  time  showed  much  mucus,  a  large  excess  of  meat  fiber, 
no  fat.  He  was  given  a  prescription  for  paregoric,  i  dram,  to  be 
repeated  after  each  loose  movement.  On  the  28th  of  April,  1914,  the 
patient  reported,  at  my  request.  He  then  weighed  170  pounds,  with 
clothes,  and  averaged  about  four  days'  work  a  week.  He  never  has 
any  looseness  of  the  bowels  or  any  movements  at  night,  but  he  is  still 
bothered  with  gas,  cramps,  and  loose  movements  in  the  daytime. 
Spinach,  prunes,  and  pie  are  especially  likely  to  upset  him.  He  has 
seen  no  blood  in  his  movements,  but  thinks  they  contain  consider- 
able pus. 

The  cause  of  this  diarrhea  I  do  not  know. 

Case  97 

A  laborer  of  forty-five  entered  the  hospital  July  24,  191 2.  The  pa- 
tient has  always  been  well.  Takes  two  or  three  beers  and  one  whisky 
a  day.  Two  weeks  ago  he  began  to  have  diarrhea,  loss  of  appetite, 
poor  sleep.  He  had  been  working  on  a  stone-crusher  in  great  heat, 
but  as  he  felt  no  better  when  he  stayed  away  from  work  a  couple  of 


DIARRHEA 


247 


days,  he  resumed  his  occupation;  a  week  ago  he  gave  up  once  more, 
although  he  has  not  felt  very  sick.  He  has  no  headache  and  no  other 
symptoms.  Ten  years  ago  he  weighed  175  pounds;  one  year  ago, 
150  pounds;  now,  139  pounds. 

Physical  examination  shows  the  patient  well  nourished,  active, 
and  bright  mentally.  Right  pupil  smaller  than  the  left.  Both  react 
normally.  Tongue  clean.  Heart's  apex  in  the  fifth  space,  inside 
the  nipple  line.  Loud,  blowing  systolic  murmur  heard  all  over  the 
precordia,  not  replacing  the  first  sound.  Pulmonic  second  not  ac- 
centuated. Systolic  blood-pressure,  115.  Lungs,  abdomen,  and 
extremities  negative.     Temperature   as   seen   in   the   accompanying 


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Fig.  95. — Chart  of  Case  97. 

chart  (Fig.  95).  Urine  averages  40  ounces  in  twenty-four  hours,  with 
a  specific  gravity  1026  to  1032,  and  occasionally  a  granular  cast. 
Blood-culture  shows  pneumococci.  The  Widal  reaction  is  positive. 
White  cells,  5500,  July  24th;  4500,  July  26th;  4600,  August  2d;  4000, 
August  nth;  6000,  August  21st.  The  spleen  was  never  felt  and  no 
rose  spots  were  seen. 

Discussion. — During  the  early  weeks  of  observation  no  diagnosis 
could  be  made.  A  latent  acute  endocarditis  or  a  deep  lying  broncho- 
pneumonia were  thought  the  most  probable  explanations  of  his 
symptoms.  Against  both  of  these,  however,  a  persistently  low  leuko- 
cyte count  had  to  be  considered.     Without  the  positive  Widal  reac- 


248  DIFFERENTIAL  DIAGNOSIS 

tion  we  should  have  been  utterly  in  the  dark.  As  it  is,  the  positive 
blood-culture  remains  a  mystery.  It  may  have  been  a  false  report. 
Typhoid  fever  seems  to  me  clearly  the  diagnosis. 

Outcome. — August  2  2d  the  patient  seemed  to  be  well  and  left 
the  hospital. 

Case  98 

A  hotel  worker  of  thirty-one  entered  the  hospital  September  27, 
191 2.  The  patient's  father  died  at  sixty  of  dysentery;  otherwise  the 
family  history  is  not  of  interest.  The  patient  had  left-sided  pleu- 
risy when  seventeen,  but  had  otherwise  been  well  until  he  was  twenty- 
four,  when  he  had  a  diarrhea  lasting  six  months.  He  was  in  Aus- 
tralia at  this  time.  After  that  he  was  well  until  six  months  ago, 
when  the  bowels  began  to  be  loose  and  occasionally  a  Httle  blood  was 
noticed  in  the  movements,  yet  the  condition  had  not  been  trouble- 
some until  about  two  months  ago,  when  he  began  to  suffer  from 
tenesmus  and  noticed  mucus  in  the  stools  and  a  little  cramp-like  pain 
in  the  lower  abdomen  and  before  movements.  Still  the  frequency  of 
stools  was  not  much  increased  until  within  the  past  month,  when 
all  his  symptoms  had  been  aggravated  and  his  appetite  and  strength 
had  failed.  Proctoscopy  in  the  surgical  Out-patient  Department 
September  17,  191 2,  was  negative. 

Physical  examination  showed  a  man  well  nourished  and  appar- 
ently not  much. pulled  down.  The  viscera  were  entirely  negative. 
The  temperature  during  the  seven  weeks  in  the  ward  was  not  ele- 
vated. The  blood  and  urine  not  remarkable.  Systolic  blood-pres- 
sure, 130.  The  stools  were  liquid  and  always  showed  a  positive  guaiac 
reaction,  with  numerous  pus  cells  and  red  corpuscles  under  the  micro- 
scope, but  no  macroscopic  pus  or  blood.  The  gas  bacillus  was  abun- 
dant in  the  stools.  No  amebae  or  eggs  were  found  in  the  stools.  Under 
the  Schmidt  diet  the  frequency  of  stools  was  somewhat  improved,  but 
the  quality  not  much  changed  until  October  6th,  when  they  became 
formed  and  occurred  only  once  a  day.  On  the  14th  the  patient  was 
put  on  special  diet,  consisting  of  meat,  400  grams;  toast,  40  grams; 
four  eggs,  and  enough  macaroni,  cheese,  and  butter  to  bring  the  value 
up  to  2000  calories.  This  produced  no  special  change,  and  on  the  17th 
the  patient  was  given  strict  diabetic  diet,  with  50  grams  of  carbo- 
hydrates, 75  grams  of  protein,  and  enough  fat  to  make  up  3000 
calories.  On  this  diet  the  stools  became  more  frequent,  and  on  the 
20th  he  was  given  a  fat-free  diet  for  a  few  days,  without  improve- 
ment.    He  then  was  once  more  put  upon  the  special  diet  previously 


DIARRHEA  249 

ordered  on  the  14th,  and  showed  a  very  marked  improvement.  On 
the  7th  of  November  he  was  given  butter  and  potato  in  addition  to 
the  foods  previously  allowed,  but  this  did  not  work  well,  and  on  the 
loth  he  was  again  restricted  to  the  special  diet  above  listed.  Im- 
provement once  more  followed,  and  he  was  allowed  to  go  home  on 
the  13th  of  November  in  good  condition. 

Discussion. — This  case  is  typical  of  a  mild  degree  of  ulcerative 
coHtis.  It  is  interesting  chiefly  because  of  the  dietetic  experiments 
tried. 

Outcome. — The  patient  was  seen  December  13,  1912,  and  stated 
that  for  the  first  two  weeks,  since  leaving  the  hospital,  he  was  as 
badly  off  as  ever.  Since  then  he  has  been  much  better,  and  though 
he  has  not  yet  gone  to  work,  he  expects  to  do  so  within  another  week. 
For  the  first  two  weeks  after  leaving  the  hospital  he  had  diarrhea 
between  2  and  9  a.  m.  each  day,  with  complete  freedom  from  such 
trouble  for  the  rest  of  the  day.  Now  he  has  but  one  movement  a 
day,  which  is  preceded  by  some  griping  pain.  There  is  no  blood  in 
the  stools.  He  states  that  cold  meat  always  agrees  with  him,  while 
hot  meat  makes  his  bowels  loose.  He  has  taken  no  medicine  lately, 
eats  and  sleeps  well,  and  feels  as  well  as  ever. 


CHAPTER  IV 

DYSPEPSIA 

The  vast  majority  of  the  causes  for  indigestion  have  nothing  to  do 
with  the  stomach,  that  is,  with  any  disease  of  the  stomach.  There 
is  not  an  organ  in  the  body  which  may  not  produce  gastric  symptoms. 
The  vomiting  of  brain  tumor  and  of  uremia  are  familiar  examples. 
Indeed,  I  think  we  should  recognize  the  fact  that  the  stomach  may  be 
thrown  out  of  its  regular  routine  of  work  almost  as  easily  as  the 
heart.  We  are  perfectly  famihar  with  the  fact  that  any  bodily  and 
mental  exertion  and  any  sort  of  illness  may  increase  the  heart-beat. 
We  do  not,  therefore,  suspect  any  disease  of  the  heart  itself.  We 
must  learn  to  be  as  familiar  with  the  fact  that  when  patients  com- 
plain of  their  stomachs  they  are  generally  free  from  gastric  disease. 
This  is  the  more  important  because  the  patient's  own  well-meaning 
efforts  go  very  far  to  mislead  us.  A  patient  whose  heart  happens  to 
be  rapid,  by  reason  of  some  disturbance  in  another  part  of  the  body, 
is  not  apt  to  complain  of  his  heart,  but  if  a  patient  has  any  stomach 
trouble  he  always  complains  of  his  stomach,  no  matter  where  the 
trouble  originates.  Gastric  complaints  are  very  urgent;  they  press 
themselves  very  forcibly  on  our  notice  and  bulk  large  and  gloomy 
in  the  foreground.  This  is  the  source  of  the  old  medical  adage  that 
"patients  with  disease  above  the  waist  are  cheerful;  those  with  dis- 
ease below  the  waist  are  despondent."  Disease  below  the  waist 
means  something  that  produces  gastric  symptoms,  and  gastric  symp- 
toms are,  as  I  have  just  said,  very  plangent,  affecting  our  spirits 
strongly. 

The  truly  gastric  causes  of  indigestion  may  be  reduced  almost 
entirely  to  two — cancer  and  ulcer.  Nervous  dyspepsia  is  fearfully 
common,  but  it  does  not  originate  in  the  stomach.  It  is  so  with  the 
other  varieties,  such  as  functional  hypochlorhydria,  dyspepsia  de- 
pendent upon  constipation,  and  other  types  to  be  mentioned  later. 
They  do  not  in  any  sense  deserve  to  be  called  gastric  disease. 

What,  then,  should  be  especially  present  in  our  minds  as  possible 
causes  of  gastric  symptoms,  when  a  patient  comes  to  us  for  these  and 
for  these  alone? 


DYSPEPSIA  251 

(i)  In  a  woman  who  has  not  passed  the  menopause,  pregnancy 
should  always  be  remembered  as  a  possibility.  I  have  known  a 
number  of  cases  unsuccessfully  treated  for  stomach  trouble  without 
any  investigation  for  the  possibility  of  pregnancy,  although  the  latter 
was  later  found  to  be  the  entire  cause  of  the  gastric  complaint.  I  do 
not  think  there  is  any  characteristic  peculiarity  about  the  stomach 
symptoms  of  pregnancy.  The  early  morning  nausea  and  the  vomiting, 
which  are  so  often  present,  are  also  seen  in  dyspepsia  of  the  uremic 
type,  in  lead-poisoning,  in  alcoholism,  and  in  phthisis. 

(2)  Chronic  nephritis  is  much  more  often  a  cause  of  dyspepsia 
than  most  of  us  recognize.  It  is,  of  course,  the  types  of  nephritis 
which  do  not  produce  edema  or  obvious  changes  in  the  urine  which 
are  most  likely  to  mislead  us.  In  my  own  experience,  it  has  been 
chiefly  the  vascular  types  of  nephritis,  associated  with  arteriosclerosis 
of  the  heart  and  brain,  that  have  caused  mistakes,  owing  to  the  pres- 
ence of  indigestion  as  a  presenting  symptom.  Since  it  has  become  a 
matter  of  routine  for  all  conscientious  physicians  to  measure  the 
systolic  blood-pressure  in  every  patient,  mistakes  of  this  sort  are  less 
and  less  frequent,  for  the  great  majority  of  nephritic  cases  associated 
with  indigestion  show  a  notably  high  blood-pressure.  A  further  dis- 
tinction between  true  gastric  disease  and  the  indigestion  due  to 
uremia  is  the  fact  that  the  latter  has  no  association  with  the  presence 
or  absence  of  food  in  the  stomach.  The  patient's  nausea  or  distress 
may  come  at  any  time  in  the  day,  after  any  kind  of  food  or  no  food 
at  all.  It  is  utterly  irregular.  Further  proof  that  the  indigestion 
is  of  uremic  origin  may  be  obtained  by  treating  the  patient  for  uremia. 
Rest  in  bed,  low  protein  diet,  purgation,  sometimes  venesection  or 
hot-air  baths,  should  produce  improvement,  unless  the  patient  is  in 
the  last  stages  of  the  illness. 

(3)  Tuberculosis,  pulmonary  or  other,  is  very  frequently  over- 
looked because  gastric  symptoms  are  all  that  the  patient  complains 
of.  Unexplained  indigestion  coming  on  in  a  person  previously  healthy, 
in  a  person  who  has  not  changed  his  diet  or  his  work,  who  is  not 
anemic  or  nephritic  or  overwhelmed  by  mental  torture  and  worry, 
should  be  suspected  of  being  due  to  tuberculosis.  True  gastric 
indigestion  should  have  a  demonstrable  cause,  either  a  local  cause 
in  the  stomach  itself  (cancer  or  ulcer),  or  an  external  cause  in  some 
obvious  indiscretion  in  diet.  Such  indiscretions  are  much  less  common 
than  the  diagnosis  of  them.  We  often  badger  the  patient  and  force 
him  into  the  reluctant  admission  that  he  has  eaten  something  out  of 
the  way,  when,  in  point  of  fact,  he  has  not.     We  are  so  determined 


Dyspepsia 

NON-GASTRIC   BH^Hl^^^^l^HHHaiHBHHIi^lH^H^BaB  12,612 

GASTRIC        ^^mmam  2,697 


^  Including   cancer,    ulcer,    and   the   anomalies   of    gastric    secretion,    size,   and 
position. 


252 


Dyspepsia 


DEBILITATED  STATES 

INDUSTRIAL  OVERSTRAIN 

ALCOHOLISM 

FAILING  HEART  ■ 

PHTHISIS  ■ 


CASES    TOO    MANY   AND    TOO  VAGUELY    ENUMERABLE    FOR 
GRAPHIC    REPRESENTATION. 


ANEMIA    AND    CHLO- 
ROSIS 

NEUROSIS   AND    PSY- 
CHONEUROSIS 

CHRONIC   NEPHRITIS 

GASTRIC  ULCER 

GASTRIC  CANCER 

DYSPEPSIA    (UN- 
KNOWN   CAUSE) 


CANCER       OF 
BOWEL 


THE 


GALL-STONES 

CONSTIPATION 

CIRRHOTIC  LIVER 

GASTRITIS,  GASTRO- 
ENTERITIS, ALCO- 
HOLIC GASTRITIS 

NERVOUS  DYSPEPSIA 

DUODENAL  ULCER 

GASTRECTASIA 

LEAD-POISONING 

GASTROPTOSIS 

HYPERCHLORHYDRIA 

HYPOACIDITY 

TABES 


2922 
1929 

1925 

1482 

1197 
1140 
1050 

624 

624 

620 
605 
553 

546 

459 
360 
271 
174 
130 
109 
28 
22 


253 


254 


DIFFERENTIAL  DIAGNOSIS 


to  find  a  case  of  this  nature  that  we  find  it  even  when  it  is  not  there. 
A  more  sensible  course  would  be  to  have  the  patient's  temperature 
measured  night  and  morning  for  a  week,  inquire  carefully  into  his 
family  history,  and  to  examine  his  lungs  with  the  utmost  care  in  a 
perfectly  quiet  room,  and,  if  possible,  by  the  x-Ta.y  as  well  as  by  the 
ordinary  methods.  It  is  surprising  how  many  cases  of  unexplained 
dyspepsia  will  yield  to  treatment  directed  toward  tuberculosis  and 
to  no  other  treatment. 

(4)  In  women  a  great  many  cases  of  indigestion  are  due  to  star- 
vation. This  comes  about  as  follows:  Something,  we  need  not  now 
inquire  what,  produces  an  upset  of  digestion.  The  patient  attributes 
it  to  certain  food,  probably  what  she  took  last,  just  before  the  attack 
occurred.  Accordingly,  in  future  she  omits  this  article  of  diet  from 
her  bill  of  fare.  The  indigestion  recurs,  an  article  of  diet  is  again 
blamed,  and  something  else  is  cut  out  of  the  diet  because  she  thinks 
it  hurts  her.  So  in  this  way  food  after  food  is  given  up,  until  the 
patient  gets  down  to  a  regimen  of  slops  or  their  equivalent.  We  have 
now  a  typical  vicious  circle.  The  patient  is  ill-nourished  because  she 
is  dyspeptic,  and  she  is  dyspeptic  because  she  is  ill-nourished.  We 
can  break  this  circle  by  forcing  her  to  eat  despite  grievous  suffering. 
An  ill-nourished  stomach  will  complain,  yet  it  must  be  nourished 
nevertheless.  If  we  can  persuade  the  patient  to  undergo  such  suffer- 
ing, we  can  honestly  hold  out  the  hope  that  at  the  end  of  it  she  will 
break  her  chain,  will  get  back  her  nutrition,  and  lose  her  symptoms. 
The  trouble  is  that  ordinarily  the  physician  does  not  believe  this 
himself.  He  has  not  seen  enough  cases  in  which  forcing  the  patient 
to  eat  achieves  this  happy  result;  but  anyone  with  extensive  hospital 
experience  knows  that  what  is  called  "dieting" — that  is,  cutting  out  of 
one's  diet  most  of  the  foods  that  ordinary  people  live  on — is  usually  a 
most  pernicious  process,  and  leads  to  a  great  deal  of  long  and  unneces- 
sary suffering.  Most  cases  of  this  type  can  be  cured  by  nothing  in  the 
world  but  forced  feeding. 

The  greatest  improvement  that  I  have  seen  in  the  management  of 
stomach  cases  in  the  last  twenty  years  has  been  the  recognition  of 
causes  outside  the  stomach  and  the  successful  attack  upon  these  causes. 
Next  to  this,  the  greatest  improvement  has  been  through  giving  up 
our  habits  of  making  strict,  narrow  diet  fists  which  result  in  more  or 
less  chronic  starvation.  Whatever  we  do  for  a.  gastric  patient,  we 
must  not  starve  him.  We  must  get  in  food  enough  to  maintain  the 
caloric  needs  of  the  body,  and  the  greatest  error  in  the  treatment  of 
the  past  has  been  the  failure  to  recognize  this  necessity. 


DYSPEPSIA  255 

(5)  Gall-stones  are  a  very  frequent  cause  of  attacks  attributed  to 
the  stomach.  When  cancer  and  ulcer  can  be  excluded,  it  is  almost 
invariably  wrong  to  attribute  to  the  stomach  any  malady  that  causes 
severe  pain.  Otherwise  stated,  the  only  gastric  diseases  that  cause 
severe  pain  are  cancer  or  ulcer.  All  other  forms  of  indigestion  run 
their  course  with  varying  degrees  and  combinations  of  flatulence — 
heart-burn,  distress,  pressure,  nausea,  vomiting,  but  not  with  severe 
pain. 

Now,  gall-stones  often  produce  pain  squarely  in  the  pit  of  the 
stomach  and  not  in  the  region  of  the  gall-bladder.  Failure  to  realize 
this  accounts  for  many  mistakes.  If  the  patient  has  many  attacks, 
some  of  them  are  likely,  sooner  or  later,  to  be  localized  in  or  to  radiate 
to  the  right  hypochondrium,  but  in  the  early  stages  of  the  disease  we 
may  not  have  any  such  symptom.  True  stomach  trouble  rarely 
begins  in  the  night.  Gall-stone  pains  are  very  apt  to  begin  in  the 
night.  Gall-stone  pains  are  generally  reheved  promptly  and  per- 
manently by  morphin.  Gastric  disease  can  seldom,  if  ever,  be  so 
relieved.  Further  details  as  to  this  differential  diagnosis  will  be  given 
later  in  this  chapter. 

(6)  Angina  pectoris  is  again  and  again  treated  for  dyspepsia. 
The  pain  may  be  at  the  epigastrium,  and  is  very  often  preceded  or 
accompanied  by  flatulence  and  belching.  Moreover,  it  not  infre- 
quently comes  after  meals.  These  three  facts,  taken  together,  lead 
to  many  erroneous  diagnoses  of  stomach  trouble,  when  a  measure- 
ment of  blood-pressure  or  a  careful  history  would  have  revealed  the 
obvious  presence  of  angina  pectoris.  A  characteristic  of  angina  pain 
is  that  it  is  almost  invariably  excited  by  exertion  or  emotion,  and 
promptly  quelled  by  rest  and  peace.  Gastric  indigestion  does  not 
behave  this  way.  In  the  majority  of  cases  careful  questioning  brings 
out  the  additional  fact  that  epigastric  pain  of  anginoid  origin  is  asso- 
ciated, sooner  or  later,  with  pain  in  the  left  arm. 

Why  angina  attacks  are  associated  with  belching  I  have  no  idea. 
It  may  be  that  this,  like  most  belching,  is  really  due  to  air  sucking, 
produced  by  the  attempt  to  gain  rehef  from  previous  gastric  discom- 
fort, and  followed  by  the  discharge  of  the  air  thus  sucked  into  the 
stomach.  Why  do  angina  attacks  sometimes  come  after  meals? 
Because  the  muscular  work  of  digestion,  like  any  other  muscular  work, 
increases  the  work  of  the  heart. 

(7)  Tahes  Dorsalis. — Among  136  gastric  cases  reported  by  Dr. 
Frederick  T.  Lord  before  the  Bristol  County  Medical  Societ}^  at  Fall 
River,  May  14,  1914,  12  were  tabetics,  and  3  of  these  were  operated 


256  DIFFERENTIAL  DIAGNOSIS 

upon  for  supposedly  local  disease  of  the  abdomen.  Such  a  mistake 
is  inexcusable  when  previous  evidence  of  tabes,  such  as  an  Argyll- 
Robertson  pupil  or  absent  knee-jerks,  can  be  obtained.  But  we  have 
had  at  least  2  cases  in  which  the  syphihtic  nature  of  the  under- 
lying disease  was  discoverable  only  by  lumbar  puncture,  the  pupils 
and  knee-jerks  being  normal.  What  we  are  learning  in  the  last  few 
years,  since  lumbar  punctures  and  Wassermann  reactions  in  the  blood 
and  spinal  fluid  have  become  matters  of  routine  in  doubtful  gastric 
cases,  is  that  any  type  of  stomach  trouble,  acute  or  chronic,  mild  or 
severe,  sharply  painful  or  merely  distressing,  may  he  due  to  cerebro- 
spinal syphilis.  Until  within  the  past  few  years  one  was  on  the  look- 
out, if  he  were  conscientious,  for  so-called  gastric  crises  in  tabes,  i.  e., 
for  sudden  paroxysmal  attacks  of  abdominal  pain  and  vomiting,  asso- 
ciated with  the  obvious  nervous  lesions  of  posterior  spinal  sclerosis. 
What  we  have  learned  lately  is — 

(a)  That  we  must  suspect  the  possibility  of  tabes,  even  when  the 
pupils  and  knee-jerks  are  normal,  and  must  investigate  this  possi- 
bility by  means  of  spinal  puncture. 

{b)  That  any  sort  of  gastric  abdominal  pain  or  distress  may  be 
due  to  tabes. 

Actual  syphilitic  disease  of  the  stomach,  resulting  in  an  hour- 
glass configuration  of  the  organ  or  in  scars  of  other  kinds,  must  be 
remembered  as  a  possibiHty  and  investigated,  so  far  as  possible. 

(8)  Lead-poisoning  is  not  a  common  cause  of  indigestion  among 
well-to-do  people,  but  among  factory  workers,  especially  rubber 
workers,  painters,  and  printers,  it  is  much  more  common  than  is 
ordinarily  recognized.  Any  causeless  dyspepsia  in  a  person  exposed 
to  lead  and  even  any  causeless  loss  of  appetite  should  be  suspected  of 
being  due  to  lead-poisoning.  When  this  dyspepsia  is  associated  with 
colic,  and  especially  when  a  lead  Hne  or  characteristic  blood  changes 
are  present,  there  is  no  excuse  for  failing  to  make  the  diagnosis,  but 
in  the  earhest  cases  we  cannot  get  beyond  a  presumption,  and  we 
should  act  upon  this  presumption  by  urging  the  patient  to  put 
himself,  at  any  rate  for  a  time,  under  conditions  in  which  lead  ab- 
sorption is  impossible.  If,  then,  he  rapidly  improves,  he  should  be 
urged  either  to  change  his  job  or  to  take  more  effective  precautions 
against  the  ingestion  of  lead. 

(9)  Cancer  of  the  large  intestine  sometimes  deceives  even  the 
elect  when  presenting  itself  with  irregular  periods  of  nausea,  dis- 
tress and  vomiting,  and  without  any  special  intestinal  complaints. 
I  have  known  such  cases  in  which  there  was  no  flatulence,  no  severe 


DYSPEPSIA  257 

pain,  and  no  more  constipation  than  might  be  associated  with  any 
t3^pe  of  indigestion  or  even  with  seasickness.  Should  any  question 
arise,  a  bismuth  enema  and  x-ray  study  should  be  carried  out  and, 
if  a  doubt  still  remains,  exploratory  incision  should  be  advised. 

(10)  Organic  cerebral  disease,  arteriosclerosis,  syphilis,  or  tumor 
are  not  often  mistaken  for  indigestion;  headache  and  vertigo  usually 
call  attention  to  the  brain.  It  should  be  remembered,  however,  that 
all  of  these  cerebral  lesions  may  be  associated  for  weeks  and  months 
with  headaches  of  a  type  ordinarily  called  "biUous"  and  attributed  to 
indigestion.  Such  attacks  are  often  unilateral  and  get  called  "mi- 
graine." This  mistake  can  only  be  avoided  by  early  and  frequent 
examination  of  the  fundus  oculi  and  by  a  careful  history,  such  as  will 
bring  out  transient  paresthesias  of  one  or  another  extremity,  transient 
fits  or  paresis, '  aphasia,  or  clouding  of  consciousness. 

(11)  Industrial,  mental,  and  moral  causes  of  indigestion  are  very 
common  and,  by  physicians  not  trained  to  investigate  every  part  of 
the  patient's  life,  often  unrecognized.  Fatigue,  worry,  fear,  or  re- 
morse may,  quite  unknown  to  the  patient,  be  at  the  bottom  of  his 
sufferings.  In  the  hospital  a  social  service  worker  is  indispensable  in 
the  diagnosis  and  treatment  of  such  cases. 

WHAT  IS  SIMPLE  INDIGESTION? 

When  the  stomach  is  upset,  yet  is  free  from  organic  disease,  and, 
so  far  as  we  can  ascertain,  from  any  outside  influences,  such  as  those 
which  have  been  detailed  in  the  preceding  paragraphs,  what  has 
occurred?  We  are  very  apt  to  say  that  the  patient  has  eaten  some- 
thing indigestible,  and  doubtless  this  is  sometimes  true,  although  I 
think  it  is  rarely  a  sufl&cient  explanation.  Or,  again,  we  say  that 
gastric  fermentation  has  occurred;  but  this  is  always  secondary  to 
some  cause  producing  arrest  of  digestion  and  stasis  of  gastric  con- 
tents. This  is  where  our  attention  should  be  focused.  In  healthy 
persons,  now  and  then,  something  causes  an  arrest  of  digestion. 
The  gastric  contents  are  not  passed  on  into  the  duodenum.  They 
remain  in  the  stomach  and  undergo  abnormal  fermentation,  causing 
flatulence  and  other  forms  of  distress.  But  why  do  they  remain  in  the 
stomach?  What  inhibits  digestion?  Two  causes  are  known,  others 
suspected. 

{a)  We  know  that  severe  bodily  exertion  immediately  after  a 
meal  may  slow  or  altogether  stop  digestion,  presumably  by  caUing 
away  so  much  blood  from  the  stomach  that  its  motihty  is  interfered 
with. 

Vol.  11—17 


258  DIFFERENTIAL  DIAGNOSIS 

(b)  Psychic  disturbances,  such  as  fear,  grief,  rage,  worry,  may 
frequently  upset  digestion  by  slowing  or  inhibiting  the  gastric  move- 
ments, possibly  also  by  affecting  secretion.  One  cannot  help  being 
somewhat  skeptical  as  to  the  importance  of  secretion,  its  lack  or  excess, 
when  we  see  how  well  patients  with  tabes  or  pernicious  anemia  may 
digest  their  food  for  long  periods  of  time  without  any  HCl  discover- 
able in  the  gastric  contents.  I  am  not  yet  convinced  that  deficient 
gastric  secretion  is,  in  itself,  enough  to  produce  dyspepsia.  Many 
tired,  anemic,  or  tuberculous  patients  have  deficient  gastric  secretion 
and  also  indigestion,  but  in  these  cases  motiHty  is  usually  disturbed  as 
well.  When  motility  is  good  and  secretion  absent,  as  in  diabetes, 
digestion  seems  to  go  on  perfectly  well. 

Beyond  the  two  known  causes  for  gastric  inhibition — bodily 
exertion  and  excessive  emotion — there  are  doubtless  many  others, 
concerned,  perhaps,  with  the  action  of  the  glands  of  internal  secretion 
about  whose  bearing  and  suggestion  we  know,  at  present,  very  little. 
What,  it  seems  to  me,  important  that  we  should  recognize  is  that  the 
majority  of  all  gastric  upsets  are  not  easily  explained,  and  that  the 
old  idea  of  improprieties  in  diet  has  been  seriously  overworked.  If 
we  will  recognize  how  little  we  know  in  this  field,  we  may  progress 
more  rapidly. 

Case  99 

A  shoemaker  of  sixty-seven  entered  the  hospital  May  16,  1908. 
The  patient's  mother  died  of  cancer  of  the  throat  at  sixty-eight;  other- 
wise his  family  history  is  good.  He  was  sick  for  a  month,  when  twenty 
years  old,  with  a  fever  of  unknown  nature.  He  says  he  has  had  dys- 
pepsia all  his  life,  distress  after  eating  being  the  chief  symptom. 
There  has  been  no  vomiting.  Four  months  ago  he  weighed  175 
pounds,  with  clothes;  now,  142^  pounds,  without  clothes. 

Four  months  ago  his  dyspeptic  symptoms  became  worse,  and  he 
began  to  have  sharp,  constant  pain  in  the  epigastrium,  not  radiating 
and  not  affected  by  food.  At  times  this  pain  is  severe  enough  to  double 
him  up.  For  three  weeks  he  has  had  nausea  and  vomiting  immediately 
after  meals,  with  some  relief  of  pain.  The  vomitus  shows  no  blood  or 
coffee-grounds  and  no  food  taken  the  previous  day.  For  the  past 
month  he  has  eaten  almost  nothing,  and,  according  to  his  statement, 
his  bowels  have  moved  but  twice  during  this  time.  He  has  emptied 
his  stomach  either  by  vomiting  or  by  the  help  of  the  stomach-tube 
each  day. 

Physical   examination   showed   rather  poor  nutrition,    skin   and 


DYSPEPSIA 


259 


mucous  membranes  pale,  but  was  otherwise  negative.  Weight,  142  { 
pounds,  without  clothes.  Temperature,  blood,  and  urine  negative. 
With  the  stomach-tube  no  contents  were  obtained  from  the  fasting 
stomach.  The  capacity  of  the  organ  was  84  ounces.  When  inflated 
it  occupied  the  position  shown  in  Fig.  96.  After  a  test-meal  free  HCl 
was  present,  0.18  per  cent.;  total  acidity,  0.26  per  cent.  Guaiac 
negative.  Microscopic  examination  negative.  The  patient  improved 
markedly  on  a  liquid  and  soft  solid  diet  with  nux  vomica  and  a 
laxative. 


Fig.  96. — Gastric  outlines  in  Case  99. 

Gastric  neurosis  was  the  preliminary  diagnosis.  On  the  24th  he 
had  moderately  positive  guaiac  test  in  the  stools.  Tube  examina- 
tion of  the  stomach  was  repeated  on  the  26th,  with  practically  identi- 
cal results.  The  patient  was  examined  in  a  warm  bath  and  seen  by 
several  consultants.  Nothing  further  developed.  He  ate  and  slept 
well  and  felt  subjectively  much  better.  Lavage  was  repeated  every 
third  morning.  A  surgical  consultant  saw  no  indication  for  operation, 
and  the  patient  left  the  hospital  on  the  6th  of  June  very  much  im- 
proved. 

He  re-entered  on  the  6th  of  July,  1908,  having  done  no  work  since 
he  left  before,  and  having  Uved  upon  a  diet  of  milk,  crackers,  grape- 


26o  DIFFERENTIAL   DIAGNOSIS 

nuts,  and  eggs.  Once  he  took  clam  chowder  and  vomited,  but  this 
was  the  only  time.  He  has  no  pain  except  when  he  takes  a  deep 
breath  or  on  certain  motions,  and  he  has  no  distress  except  after  a 
hearty  meal.  His  belching  has  not  returned.  His  bowels  move  every 
other  day.     He  has  dull,  constant  headache. 

Physical  examination  shows  poor  nutrition,  but  is  otherwise  nega- 
tive. Blood  and  urine  negative.  Stomach-tube  examination  showed 
a  little  food  residue  in  the  fasting  stomach.  Guaiac  test  on  that 
residue  negative.  After  a  test-meal  free  HCl  was  present,  0.18  per 
cent.;  total  acidity,  0.26  per  cent.  Guaiac  test  in  the  stools  was 
positive  on  the  9th,  12th,  and  13th.     His  weight  was  140  pounds, 

2  pounds  less  than  at  the  previous  entrance. 

Discussion. — The  age,  the  family  history,  and  loss  of  weight 
point  toward  cancer,  but  we  note  also  that  this  patient  has  been 
dyspeptic  all  his  life,  and  that  his  pain  does  not  seem  to  be  affected 
by  food  and  is  more  severe  than  we  usually  see  in  gastric  cancer. 
It  is  rare  to  hear  a  person  say  that  the  pain  doubles  him  up  when 
gastric  cancer  turns  out  to  be  the  cause. 

Physical  examination  shows  a  large  but  apparently  competent 
stomach.  There  is  practically  no  stasis,  always  the  most  important 
thing  to  know  about  a  stomach.  This  does  not  exclude  cancer,  but 
militates  more  or  less  against  such  a  diagnosis,  because  at  least  three- 
fourths  of  all  gastric  cancers  obstruct  the  pylorus  and  produce  stasis. 
The  presence  of  blood  in  the  stools  with  no  stasis,  and  an  abundant 
secretion  of  HCl,  is  quite  compatible  with  a  diagnosis  of  peptic  ulcer, 
although  the  patient's  age  makes  us  doubt  the  probability  of  this 
lesion. 

We  have  no  evidence  of  any  disease  outside  the  stomach,  such 
as  nephritis,  gall-stones,  or  tuberculosis.  On  the  whole,  gastric  cancer 
seems  the  most  probable  diagnosis. 

Outcome. — Operation  on  the  17th  of  July  showed  a  stomach  not 
enlarged,  thickening  of  the  pyloric  ring,  and  a  small,  whitish  patch  on 
the  anterior  surface  of  the  pylorus.  The  pyloric  opening  was  con- 
siderably obstructed.     On  the  duodenum  was  a  small,  whitish  patch, 

3  cm.  in  diameter,  similar  to  that  at  the  pylorus,  but  there  was  nb 
thickening  of  the  duodenal  wall.  In  the  head  of  the  pancreas  there 
appeared  to  be  a  small  tumor,  about  the  size  of  the  end  of  the  thumb. 
At  this  point  the  patient  stopped  breathing,  and  only  after  ten  min- 
utes of  artificial  respiration  could  he  breathe  spontaneously.  A  pos- 
terior gastro-enterostomy  was  then  done.  He  recovered  well  from 
operation,  but  had  rather  a  poor  appetite,  and  vomited  from  time  to 


DYSPEPSIA  261 

time  large  amounts  of  greenish  fluid.  He  left  the  hospital  August  9, 
1908.  August  19,  1909,  he  wrote  that  he  had  been  distinctly  better, 
but  not  well.  For  the  past  several  months  he  had  not  vomited  and  had 
gained  some  weight.  He  could  eat  almost  anything  in  moderation. 
His  bowels  were  normal.  March  24,  1910,  he  wrote  that  he  was 
better  than  before  operation,  had  no  pain,  and  weighed  145  pounds. 
He  felt  fuiely  at  bedtime,  but  had  some  hunger  pain  after  i  a.  m.  He 
had  done  no  work,  but  walked  two  to  four  miles  daily  and  had  done 
so  for  the  past  year. 

In  view  of  the  fact  that  this  patient  was  so  well  two  years  after  the 
operation,  we  may  feel  confident  that  no  cancerous  growth  was  over- 
looked at  the  time  of  operation.  We  cannot  say  that  any  positive 
evidence  of  ulcer  was  discovered,  but  the  obstruction  of  the  pyloric 
opening  and  ,the  whitish  patch  upon  the  duodenum  makes  it  prob- 
able that  we  are  dealing  with  a  peptic  ulcer  and  cicatrix.  The  patient's 
improvement,  after  gastro-enterostomy,  gives  support  to  this  belief. 

A  point  of  some  interest  in  the  findings  at  operation  is  the  state- 
ment that  the  stomach  was  not  enlarged,  although  when  distended 
with  water,  through  a  stomach-tube,  it  held  nearly  three  quarts. 
This  tends  to  show  that  these  measurements  by  water  distention  are 
by  no  means  conclusive.  The  most  useful  test  of  gastric  dilatation  is 
the  presence  or  absence  of  food  in  the  fasting  stomach  ten  hours  or 
more  after  the  last  meal. 

Case  100 

A  motorman  of  forty-four  entered  the  hospital  September  12, 
1900.  Two  weeks  before  entrance  the  patient  began  to  feel  tired 
and  to  lose  his  appetite.  A  week  ago  he  gave  up  work  and  went  to  bed. 
His  only  local  symptoms  are  pain  in  the  epigastrium  on  taking  food 
and  general  soreness  in  the  abdomen.  For  the  past  week  he  has 
vomited  almost  every  day  and  has  had  diarrhea.  The  pain  in  the 
epigastrium  has  been  very  severe,  requiring  poultices  and  plasters. 
For  a  week  he  has  had  fever.     No  cough  at  any  time. 

Physical  examination  showed  good  nutrition,  a  dull,  and  heavy 
expression.  Normal  pupils,  glands,  and  reflexes.  No  stiffness  of 
the  neck.  Chest  negative.  Scattered  rose  spots  on  the  abdomen. 
Some  tenderness  and  muscular  rigidity  in  the  epigastrium.  Some 
tenderness  on  the  tibiae  and  lower  calves.  On  the  14th  the  spleen 
was  also  palpable.  The  white  count  was  6000.  Widal  reaction 
strongly  positive.  Hemoglobin,  83  per  cent.  The  specific  gravity 
of  the  urine  was  1023;  slightest  possible  trace  of  albumin,  no  sugar; 


262 


DIFFERENTIAL   DIAGNOSIS 


CJ 


60 


in  the  sediment  a  few  hyaline 
and  granular  casts,  with  an 
occasional  cell  adherent,  now 
and  then  a  fresh  blood-cor- 
puscle. The  patient  ran  a  con- 
tinuous fever,  never  below  100° 
F.,  and  usually  between  101° 
and  102°  F.,  from  Septem- 
ber 12th  to  December  loth, 
practically  three  months  (Fig. 

97)- 

The  pulse  remained  be- 
tween 80  and  90  from  the  12  th 
to  the  28th  of  October,  then 
a  left-sided  orchitis  developed, 
and  the  leukocytes  rose  to 
18,600,  and  to  26,000  the  next 
day,  when  a  friction  rub  ap- 
peared in  the  left  axilla.  By 
the  2d  of  October  the  tender- 
ness and  swelling  were  gone 
from  the  testicle  and  the  fric- 
tion rub  had  disappeared. 
Nevertheless  the  pulse  con- 
tinued elevated,  and  from  Oc- 
tober 4th  to  December  30th, 
nearly  three  months,  was 
rarely  below  120,  often  above 
130.  Routine  examinations 
during  October  revealed  no 
local  complication,  but  on  the 
8th  of  October  the  white  cells 
numbered  35,600,  and  on  the 
loth,  36,000.  He  had  drenching 
night-sweats  in  the  early  part 
of  October.  After  the  middle 
of  the  month  harsh  breath- 
ing and  bronchophony  were 
detected  over  a  dull  area, 
about  the  size  of  the  palm,  in 
the  right  back  opposite  mid- 
scapula. 


DYSPEPSIA  263 

On  the  25th  of  October  the  white  cells  were  26,800,  and  there  were 
fairly  clear  evidences  of  solidification  at  the  right  apex  on  the  level 
of  the  spine  and  the  scapula,  over  an  area  the  size  of  a  silver  dollar. 
These  signs  were  vaguely  corroborated  from  time  to  time  up  to  the 
8th  of  November,  when  the  note  says  that  they  seemed  sometimes 
more  marked  than  at  other  times.  The  white  cells  were  then  41,000. 
On  the  14th  of  November  there  was  sharp  pain  in  the  splenic  region 
followed  by  a  drenching  sweat,  with  general  abdominal  rigidity.  The 
blood  at  this  time  showed  red  cells,  3,880,000;  white  cells,  40,800; 
hemoglobin,  43  per  cent.  Among  the  white  cells  there  were  88  per 
cent,  of  polynuclears,  11.8  per  cent,  lymphocytes,  0.2  per  cent,  eosino- 
phils. The  red  cells  showed  considerable  irregularity  in  size,  slight 
irregularity  in  shape.  There  were  160  normoblasts  per  cubic  milli- 
meter. November  20th  the  note  reads,  "Dr.  R.  H.  Fitz  finds  signs 
in  the  lungs  the  same."  White  cells  28,400.  December  4th  signs 
were  gone  from  the  right  lung;  white  cells,  22,800.  He  eats  very 
Httle. 

At  this  time,  although  the  patient's  temperature  was  still  over 
100°  F.,  he  was  gotten  out  of  bed,  and  within  a  week  the  temperature 
fell  almost  to  normal,  although  on  the  i8th  the  white  cells  were  still 
23,100.  On  the  29th  he  was  up  and  walking  about,  gaining  daily; 
white  cells,  12,400.  January  14th  he  was  able  to  walk  about  fairly 
well,  had  gained  6  pounds  in  two  weeks,  had  a  negative  physical 
examination,  and  was  allowed  to  go  home,  although  his  hemoglobin 
was  still  only  48  per  cent. 

Nine  years  later  he  entered  the  hospital  again,  stating  that  for 
the  first  year  after  leaving  the  hospital  before  he  felt  very  well,  then 
he  once  more  began  to  have  distress  in  the  epigastrium,  especially  on 
the  left  side.  It  was  not  increased  by  hearty  meals  and  did  not 
produce  vomiting.  Sometimes  hot  drinks  relieved  it.  This  condi- 
tion remained  unchanged  and  did  not  prevent  his  working. 

A  year  ago  the  pain  began  to  grow  worse  and  extended  also 
to  the  left  flank,  under  the  ribs.  It  was  now  described  as  a  dull,  sick- 
ening feeling. 

For  a  month  he  has  noticed  some  headache.  For  three  days 
the  pain  in  the  epigastrium  has  been  increased,  and  the  pain  in  the 
flank  has  disappeared  from  time  to  time.  During  these  days  he  has 
vomited  each  morning  once,  and  has  noticed  a  sHght  dyspnea  on  ex- 
ertion and  some  palpitation.  His  appetite,  until  the  last  week,  has 
been   excellent.     Up   to   a  year   ago  he  weighed   200  pounds   (136 


264  DIFFERENTIAL  DIAGNOSIS 

pounds  on  leaving  the  hospital  after  his  typhoid),  but  within  the 
past  year  he  has  lost  somewhat  in  weight,  and  now  weighs  167 
pounds,  without  clothes.  He  kept  at  work  until  three  days  before 
entrance. 

Physical  examination  showed  fair  nutrition,  the  right  pupil  larger 
than  the  left  and  shghtly  irregular;  both,  however,  reacting  normally. 
Glands  and  reflexes  normal.  The  heart's  impulse  seen,  felt,  and 
percussed  in  the  fifth  interspace;  nipple  line  11  cm.  from  midsternum. 
Right  border  of  dulness  6  cm.  from  midsternum.  At  the  apex  the 
second  sound  was  louder  than  the  first,  which  was  accompanied  by  a 
harsh,  systoUc  murmur,  loudest  in  the  apex  region.  The  aortic  second 
sound  was  markedly  accentuated.  The  arteries  thickened  and  tor- 
tuous. Blood-pressure,  260  mm.  Hg.  The  lungs  were  negative, 
save  for  sHght  dulness  and  crackling  rales  at  both  bases.  The  ab- 
domen showed  shifting  dulness  in  the  flanks.  There  was  a  slight 
tenderness  and  resistance  in  the  epigastrium  and  very  shght  edema 
of  the  shins.  The  urine  averaged  25  ounces  in  twenty-four  hours; 
specific  gravity  from  looi  to  1005;  albumin  a  trace;  sediment,  few 
hyalme  and  granular  casts.  Blood  negative.  During  the  first  week 
of  his  stay  in  the  hospital  the  temperature  ranged  between  99°  and 
100*^  F.  The  patient  did  not  improve  at  all.  Vomiting  and  headache, 
with  poor  sleep,  continued  despite  purgation,  hot-air  baths,  and 
cardiac  stimulation.  On  the  6th  leeches  were  applied  over  the  Hver. 
Very  free  bleeding  followed.  Next  day  the  vomiting  and  general 
condition  seemed  improved,  but  his  arms  had  meantime  become  very 
much  swollen  and  tender.  After  the  loth  of  March  edema  of  the 
feet  and  legs  increased.  He  took  Uttle  food,  passed  less  urine,  com- 
plained of  dyspnea  and  precordial  distress,  not  reheved  by  nitro- 
glycerin or  amyl  nitrite.  On  the  loth  he  had  an  attack  of  very  severe 
precordial  pain  with  dyspnea  which  was  not  reheved.  At  six  in  the 
evening  he  died. 

Discussion. — There  is  no  reason  to  doubt  that  the  illness  from 
which  this  patient  suffered  in  September,  1900,  was  typhoid,  with 
thrombi  in  the  lung  and  spleen.  Doubtless  the  pyrexia  toward  the 
end  of  November  and  the  early  part  of  December  was  of  the  type 
known  as  "bed  fever,"  since  it  so  promptly  subsided  when  the  patient 
got  up.  Just  what  bed  fever  is  we  do  not  know,  but  may  surmise 
that  it  is  due  to  some  disturbance  of  metaboHsm  or  of  heat  regulation, 
connected  with  the  abnormal  existence  of  the  patient  deprived  of  the 
normal  stimuli  of  exercise  and  the  normal  variations  in  temperature. 

Nine  years  later  this  patient  suffered  from  a  dyspepsia  associated 


DYSPEPSIA  265 

with  a  good  appetite.  Had  not  the  urine  and  blood-pressure  been 
tested,  we  might  have  had  no  suspicion  of  the  true  origin  of  this 
dyspepsia  until  the  edema  of  the  peritoneum  and  lungs  appeared. 
The  latter  is  probably  of  comparatively  recent  origin,  since  the 
patient  has  only  had  dyspnea  for  a  few  days.  Uremia,  then,  is 
doubtless  the  cause  of  this  patient's  symptoms. 

We  are  accustomed  to  say  that  when  a  patient  past  forty  begins 
to  have  dyspepsia  out  of  a  clear  sky — that  is,  without  any  obvious 
cause  or  any  previous  habit — cancer  is  the  most  probable  diagnosis, 
but  when  saying  this  we  must  remember  that  the  cancer  age  is  also 
the  arteriosclerotic  age,  and,  therefore,  the  time  for  nephritis  and 
uremia.  Furthermore,  the  cancer  age  is  also  the  gall-stone  age  and 
the  age  for  angina  pectoris.  All  of  these  possibihties  should,  there- 
fore, be  investigated  before  we  settle  down  on  even  a  preHminary  diag- 
nosis of  cancer. 

Outcome.- — Autopsy  showed  chronic  glomerulonephritis;  slight 
arteriosclerosis;  hypertrophy  and  dilatation  of  the  heart;  serofibrinous 
pericarditis;  cholelithiasis;  slight  chronic  pleuritis  on  the  right. 

Case  101 

A  ship  carpenter  of  forty  entered  the  hospital  March  15,  1909. 
The  patient  was  sent  in  from  the  Out-patient  Department  (No. 
123,290)  with  a  diagnosis  of  "splenic  anemia."  His  family  history  is 
excellent.  He  states  that  ten  years  ago  he  had  what  he  calls  ''rheu- 
matism," which  began  in  the  instep  of  each  foot,  was  associated  with 
fever  for  the  first  week,  and  kept  him  in  bed  for  six  weeks.  He  says 
he  was  paralyzed  from  the  waist  down,  could  not  move  his  legs  at  all, 
and  had  much  pain  in  the  backs  of  them.  Recovery,  however,  was 
complete.  He  takes  three  or  four  beers  a  day,  some  whisky  Saturday 
nights,  and  a  pint  over  Sunday. 

Two  years  ago  he  began  to  feel  run  down,  had  considerable  cough 
when  working  in  a  dusty  mill,  but  this  cough  ceased  when  he  got  an 
out-of-door  job.  At  this  time  he  weighed  155  pounds.  Last  Decem- 
ber he  had  a  day  or  two  of  indigestion,  relieved  by  taking  salts.  At 
the  end  of  January  he  stopped  work  after  a  hard  job  aboard  ship. 
He  had  then  a  crowding  feeling  in  the  epigastrium  after  meals, 
and  an  "all  gone"  feeling  later.  He  took  an  abundance  of  salts  and 
lost  in  strength  and  weight.  This  he  has  continued  to  do  in  spite 
of  medicine  and  diet.  His  appetite  has  increased,  and  he  takes  two 
quarts  of  milk  a  day.  He  had  no  pain,  no  edema,  an  excellent  appe- 
tite, better  than  usual,  fairly  good  sleep.     Nevertheless,  he  had  to 


266 


DIFFERENTIAL   DL\GN0S1S 


stop  work  January  20th  on  account  of  weakness,  and  now  weighs  only 
125  pounds. 

Physical  examination  showed  fair  nutrition,  skin  and  mucous 
membranes  pale.  Red  cells,  3,912,000;  whites,  14,200;  hemoglobin, 
55  per  cent.;  polynuclear  leukocytes,  78  per  cent.;  lymphocytes,  21 
per  cent. ;  eosinophils,  i  per  cent.  Urine  negative.  Pupils  equal  and 
react  normally,  slightly  irregular  in  outline.  Reflexes  normal.  Glands 
enlarged  in  the  neck,  axillae,  groins,  and  epitrochlear  regions.  Artery 
walls  thickened  and  slightly  tortuous.  Visible  pulsation  in  the 
brachialis.     Chest  negative.     The  liver  extended  from  the  sixth  rib 


Fig. 


-Condition  of  the  spleen  and  liver  in  Case  loi. 


to  a  point  11  cm.  below  the  ensiform,  where  an  edge  was  felt. 
Splenic  dulness  was  11  by  15  cm.  The  edge  of  the  organ  was  felt 
(Fig.  98). 

I  made  the  diagnosis  of  questionable  syphilis  of  the  liver,  as  the 
surface  of  that  organ  was  irregular,  its  edge  rounded.  Examination 
in  a  hot  bath  showed  no  palpable  spleen,  but  otherwise  confirmed 
results  of  previous  study.  Stomach-tube  showed  no  contents  in  the 
fasting  stomach.  After  a  test-meal  there  was  no  free  HCl  or  other 
acidity.  Guaiac  was  positive.  On  the  23d  there  was  some  food 
residue  in  the  fasting  stomach.     After  a  test-meal  the  contents  were 


DYSPEPSIA 


267 


still  alkaline.  The  patient's  gastric  distress  was  considerably  re- 
lieved by  resorcin,  5  gr.  three  times  a  day,  which  was  given  after  a 
fruitless  trial  had  been  made  of  antisyphilitic  treatment.  After 
losing  7  pounds  in  the  first  week  he  got  most  of  it  back  again.  His 
temperature  was  somewhat  elevated  throughout  (Fig.  99).  His 
stools  were  always  negative  to  guaiac. 

Discussion. — ^Apparently  this  patient  had  an  alcoholic  neuritis, 
or  possibly  a  rheumatic  attack,  ten  years  ago,  and  a  decided  cough, 
possibly  tuberculous,  two  years 
ago,  but  there  seems  no  good 
reason  to  connect  either  of  these 
illnesses  with  his  present  six 
weeks'  attack  of  rather  mild 
dyspepsia,  in  which  he  has  lost 
weight  and  strength  despite  an 
excellent  appetite.  (This  last 
combination,  it  should  be  noted 
— loss  of  weight  and  an  excellent 
appetite — is  a  rather  rare  one, 
occurring  chiefly  in  diabetes  and 
Graves'  disease.) 

The  presence  of  an  unex- 
plained anemia  in  a  man  of  this 
age,  with  a  generalized  adenitis 
and  enlargement  of  the  liver 
and  spleen,  may  mean  syphilis. 
Sailors  are  notoriously  apt  to 
have  syphilis.  Whether  ship  carpenters  are  as  bad,  I  do  not  know. 
The  condition  of  the  liver  edge  gives  support  to  this  surmise,  yet  it  must 
be  confessed  that  we  have  no  positive  evidence  of  syphilis  in  this  case. 

His  habits  are  neither  of  the  best  nor  of  the  worst  as  regards 
alcohol.  It  is  certainly  possible  that  he  may  have  acquired  cirrhosis 
of  the  liver,  and  cirrhosis  might  account  for  all  his  symptoms  except 
his  adenitis  and  his  rather  premature  arteriosclerosis.  The  absence 
of  free  HCl  in  the  gastric  contents  and  the  presence  of  positive  guaiac 
reaction  are  not  infrequently  associated  with  cirrhotic  Hver. 

Why  may  not  the  patient  have  peptic  ulcer?  His  anemia  might 
be  accounted  for  by  some  unrecognizable  hemorrhage  which  passed 
out  by  the  bowel.  His  good  appetite  is  entirely  consistent  with  such 
a  diagnosis,  and  is  more  easily  explained  than  by  either  of  the  diag- 
noses previously  considered. 


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268  DIFFERENTIAL  DIAGNOSIS 

Ulcer,  however,  has  a  much  longer  history  of  paroxysmal  dys- 
pepsia than  is  present  in  this  case,  and  it  is  not  often  associated  with 
absence  of  HCl  in  the  gastric  contents. 

We  have  some  hints  of  phthisis  in  the  case,  especially  the  cause- 
less indigestion  and  the  slight  fever.  No  one  of  the  diagnoses  yet 
considered,  unless  possibly  syphilis,  will  account  for  this  fever,  and 
it  still  remains  a  mystery  in  this  case.  No  explanation  of  it  has 
ever  been  offered.  Arteriosclerosis  might  be  imagined  as  a  cause  of 
the  patient's  troubles,  even  though  his  urine  is  negative,  as  we  have 
no  blood-pressure  measurements  recorded.  An  arteriosclerotic  kid- 
ney or  arteriosclerosis  of  the  abdominal  blood-vessels  cannot  be  ex- 
cluded as  a  possible  cause  of  his  symptoms,  but  if  we  adopt  this 
theory  we  cannot  explain  his  anemia.  I  have  never  seen  any  good 
reason  to  believe  that  arteriosclerosis  can,  by  itself,  account  for 
anemia. 

Cancer  of  the  stomach  would  explain  the  anemia  and  the  achylia, 
but  not  the  fever,  enlarged  spleen,  and  good  appetite.  I  was  unable 
to  make  a  diagnosis  in  this  case,  and  recommended  exploratory  in- 
cision in  view  of  our  uncertainties. 

Outcome. — On  the  5th  of  April  operation  revealed  a  mass  in  the 
greater  curvature  of  the  stomach  and  a  larger  mass  underneath  the 
stomach.  Both  masses  were  presumably  cancerous.  No  operation 
was  attempted.  The  patient  was  sewed  up.  He  left  the  hospital 
April  25,  1909,  and  a  letter  sent  to  his  address  a  year  later  was 
returned  marked  "Dead." 

Case  102 

A  married  Russian  Jewess  of  forty-four  entered  the  hospital 
February  22,  1909.  Her  family  and  past  history  were  not  remark- 
able. For  three  months  she  has  vomited  in  the  morning  whenever 
she  takes  anything  to  eat  or  to  drink.  At  times  when  vomiting  her 
fingers  stiffen  out,  but  her  thumbs  do  not  turn  inward.  During  this 
same  period  she  has  had  some  shortness  of  breath  on  climbing  stairs, 
and  for  two  months  has  used  two  pillows  at  night  and  passed  urine 
once  in  the  night. 

Physical  examination  showed  poor  nutrition,  good  color,  negative 
pupils  and  reflexes.  The  heart  showed  no  enlargement,  but  there 
was  a  rough  systolic  murmur,  best  heard  at  the  apex  and  transmitted 
to  the  axilla.  The  pulse  showed  increased  tension,  but  no  blood- 
pressure  measurement  was  recorded.  There  was  visible  pulsation 
in  the  brachial  arteries  and  some  thickening  of  the  radials.     The 


DYSPEPSIA  269 

aortic  second  sound  was  loud  and  ringing.  Both  hands  showed  in 
the  ward  a  tendency  to  a  spastic  contraction  of  the  fingers,  with 
occasional  turning  in  of  the  thumbs.  The  httle  finger  and  fourth 
finger  would  turn  under  together,  so  as  to  make  the  knuckle  of  the 
middle  finger  very  prominent.     Vaginal  examination  was  negative. 

The  urine  averaged  35  ounces  in  twenty-four  hours;  specific 
gravity,  1005;  slight  trace  of  albumin.  No  casts.  Blood  normal. 
The  fundus  oculi  showed  narrowing  of  the  arteries  at  various  points, 
no  hemorrhages  or  areas  of  retinal  degeneration.  Stomach-tube 
revealed  no  contents  in  the  fasting  stomach  and  no  enlargement  of 
the  organ.  After  a  test-meal  there  was  no  acid  in  the  gastric  con- 
tents. Despite  various  measures  designed  to  reheve  it  the  vomit- 
ing continued  until  the  2d  of  March,  when  she  was  given  corn- 
meal  mush  and  did  very  well,  but  with  more  varied  diet  vomiting 
recurred. 

Discussion. — Morning  vomiting  in  a  woman  always  suggests 
pregnancy,  but  there  is  no  possibility  of  that  in  this  case.  Next  to 
that,  nephritis  is  the  commonest  cause  that  I  know  for  morning  vomit- 
ing. The  condition  of  the  heart  and  urine  strongly  suggests  that 
there  is  a  nephritis  in  this  case.  It  is,  moreover,  notable  that  dysp- 
nea began  at  the  same  time  as  the  vertigo. 

This  patient  is  at  the  cancer  age,  and  any  such  symptoms  be- 
ginning in  a  patient  of  that  age  who  has  never  had  stomach  trouble 
before  should  suggest  cancer,  but  we  have  here  rather  more  vomiting 
and  rather  less  evidence  of  objective  gastric  disease  than  one  expects 
with  early  gastric  cancer.  The  absence  of  HCl  in  the  gastric  contents 
is  not  in  any  way  characteristic  of  cancer,  and  does  not  constitute 
evidence  against  the  diagnosis  of  chronic  nephritis,  which  seems  to 
me  the  most  reasonable  one. 

The  contractions  of  the  fingers  are  to  be  regarded  as  tetany, 
a  disease  about  which  we  know  very  little,  except  that  it  seems  to 
have  some  association  with  gastric  dilatation  and  with  extirpation 
of  the  parathyroid  glands.  There  seems  no  good  reason  to  believe 
that  either  of  these  conditions  is  present  in  this  case.  Nevertheless, 
I  suppose  the  tetany  would  be  classed  under  the  general  type  of 
gastric  tetany. 

It  is  worth  while  noticing  that  the  vomiting  was  checked  in  this 
case  by  the  administration  of  cornmeal  mush.  I  have  seen  a  simi- 
larly successful  result  in  a  good  many  cases.  In  the  treatment  of 
vomiting,  when  starvation  does  not  suffice  and  when  the  patient  must 
be  fed,  it  is  generally  a  mistake  to  give  bland  Hquids,  such  as  milk 


270  DIFFERENTIAL  DIAGNOSIS 

and  broth.     The  patient  needs  something  with  a  fairly  strong  taste 
to  it,  and  solids  are  usually  better  than  Hquids. 

Outcome. — The  pulse  grew  steadily  weaker,  and  on  the  loth 
the  family  decided  to  take  her  home,  where  she  died  March  11,  1909. 

Case  103 

A  housewife  of  thirty-six  entered  the  hospital  April  17,  1909.  The 
patient's  father  died  of  "rheumatism  of  the  heart,"  her  husband,  of 
consumption;  one  child  also  of  consumption.  She  had  typhoid  at 
fifteen,  and  a  year  later  had  jaundice  which  lasted  almost  a  year. 

For  many  years  she  has  had  stomach  trouble,  especially  in  the 
last  three  years,  in  which  time  she  has  been  vomiting  about  twice 
a  week  and  had  pain  after  taking  food;  also  burning  sensation  in  the 
epigastrium,  with  marked  constipation.  August  31,  1908,  she  entered 
the  Boston  City  Hospital  with  a  diagnosis  of  gastromesenteric  ileus. 
The  stomach  was  found  markedly  dilated.  Posterior  gastro-enter- 
ostomy  was  done.  Four  days  after  operation  nausea  and  vomiting 
began.  September  23d  she  was  discharged  against  advice.  She 
now  states  that  since  the  operation  she  has  been  much  worse  than 
before.  She  vomits  everything  that  she  eats  and  has  constant  epi- 
gastric pain,  which  confines  her  to  bed  about  half  the  time  and  causes 
her  to  lose  weight  rapidly.     She  has  never  vomited  any  blood. 

Physical  examination  showed  fair  nutrition.  The  pupils,  glands, 
and  reflexes  normal.  Chest  negative.  Abdomen  negative,  save  for 
moderate  epigastric  tenderness.  Urine  negative.  The  blood  showed 
20,000  white  cells  with  polynuclear  leukocytosis;  hemoglobin,  85  per 
cent.  Four  days  later  the  leukocytes  were  17,600.  Later  it  was 
discovered  that  for  the  last  three  months  she  had  had  morphin  to 
reheve  the  pain,  usually  ^  to  |  gr.  Her  stomach  was  washed  out 
and  its  contents  found  to  be  mostly  bile.  She  continued  to  vomit 
and  needed  a  great  deal  of  morphin,  bromid,  and  chloral.  On  the 
23d  she  was  seen  by  Dr.  C.  A.  Porter,  who  advised  exploratory  opera- 
tion. On  learning  this  news  the  patient  stopped  howling  and  vomit- 
ing, became  cheerful  and  intelligent,  said  there  was  nothing  the 
matter  with  her  stomach,  and  that  the  only  trouble  was  she  had  been 
given  too  much  morphin.  She  said  she  would  not  be  operated  upon 
and  wanted  to  go  home.  Said  she  wanted  some  food,  was  given 
an  egg  on  toast,  turned  over,  and  slept  comfortably  all  night.  The 
next  morning  she  again  began  howhng  and  vomiting.  In  the  after- 
noon the  patient,  who  was  in  a  private  room,  was  found  with  a  towel 
wound  into  the  shape  of  a  rope.     Fearing  that  she  might  do  herself 


DYSPEPSIA  271 

harm,  the  house  officer  ordered  restramt.  The  patient  escaped 
from  the  restraint,  but  was  so  enraged  with  the  treatment  that  she 
ceased  howling  and  vomiting  and  became  rational.  After  that  she 
took  considerable  nourishment  and  vomited  less. 

Discussion. — ^A  patient  who  has  been  exposed  to  tuberculous 
infection,  has  suffered  from  a  long-standing  dyspepsia,  was  shown  at 
the  Boston  City  Hospital  to  have  a  dilated  stomach  and  has  acquired 
a  morphin  habit,  now  comes  under  observation  with  a  leukocytosis  of 
unknown  origin.  What  the  cause  of  that  leukocytosis  may  have  been 
we  are  unable  to  discover. 

As  we  read  over  the  history,  we  are  inclined  to  say  at  once,  "Oh, 
yes!  hysteria!"  but  the  question  is,  is  there  not  something  behind  her 
lack  of  mental  control?  Are  we  certain  that,  even  at  her  age,  she 
has  not  some  •  arteriosclerosis  or  cerebral  syphilis?  All  we  can  say 
on  this  point  is  that  there  is  no  evidence  of  either  trouble.  I  am 
inclined  to  think  that  it  is  correct  to  attribute  her  troubles  wholly 
to  her  mentality,  though  we  cannot  account  satisfactorily  for  the 
leukocytosis. 

It  is  a  point  of  interest  in  this  case  that  although  she  had  demon- 
strably a  dilatation  of  the  stomach,  for  which  gastro-enterostomy 
was  done  without  any  relief,  she  later  got  along  with  her  stomach 
perfectly  comfortably  when  mental  conditions  were  changed.  I  have 
become  very  skeptical  of  the  diagnosis  of  dilated  stomach  as  a  patho- 
logic entity.  I  doubt  if  we  know  enough  to  make  such  a  diagnosis 
in  the  absence  of  stasis.  We  do  not  know  how  large  a  stomach 
may  be  and  still  be  normal,  nor  what  temporary  stretching  the  organ 
may  be  subject  to  without  becoming  in  any  way  diseased  or  ineffi- 
cient. The  diagnosis  of  dilated  stomach  used  to  be  a  very  frequent 
one.  In  the  better  clinics  of  the  country  it  is  now  becoming  rare 
and,  as  it  seems  to  me,  should  disappear  altogether.  A  dilated 
stomach  with  stasis  is  important,  but  it  is  of  precisely  the  same  im- 
portance as  stasis  without  the  dilated  stomach.  In  other  words,  the 
stasis  is  the  point,  and  that  is  to  be  proved  either  by  x-ray  or,  better 
still,  as  I  think,  by  the  passage  of  the  stomach-tube  before  breakfast. 
We  cannot  be  sure  that  a  bismuth  stasis  discovered  by  x-ray  repre- 
sents the  actual  functional  ability  of  the  stomach  when  working 
upon  food  materials.  Bismuth  is,  after  all,  a  foreign  substance,  very 
different  from  anything  that  we  ordinarily  ask  our  stomachs  to  deal 
with. 

Outcome. — It  was  learned  later  that  her  mother  had  died  in  the 
Danvers  Insane  Hospital.     On  the  29th  she  left,  against  advice. 


272  DIFFERENTIAL  DIAGNOSIS 

Case  104 

A  widow  of  sixty-four  entered  the  hospital  December  18,  1911. 

She  says  she  had  stomach  trouble  for  twenty  years,  and  mentions 
"auto-intoxication"  and  "dilated  stomach"  as  causes.  Occasionally 
has  colic  or  acute  distress,  otherwise  she  has  been  well,  and,  despite 
habitual  constipation  and  frequent  headaches,  has  led  an  active  hfe. 
Now  and  then  her  activities  have  been  interrupted  by  a  paroxysm 
of  what  she  calls  "meat-poisoning,"  with  some  vomiting  and  diarrhea. 
She  passes  urine  twice  at  night.  Has  had  no  other  urinary  disturbance 
and  has  never  been  jaundiced. 

For  about  a  month  she  has  had  frequent  attacks  of  nausea  and  epi- 
gastric pain.  Ten  days  ago,  after  lunch,  she  had  a  severe  attack  of  her 
usual  trouble  and  since  then  has  been  constantly  nauseated  and 
in  pain.  She  has  been  losing  weight  and  getting  worse  in  other 
respects  for  a  month.  She  stated  that  her  bowels  had  not  moved  for 
the  ten  days  preceding  December  i6th.  She  has  taken  no  cathartics 
or  enemata.     She  has  had  considerable  cough,  but  no  fever  or  chill. 

Physical  examination  showed  a  poorly  nourished  woman,  nega- 
tive pupils  and  gums,  very  poor  teeth,  many  of  them  missing.  Chest 
showed  nothing  of  interest  except  a  scattering  of  coarse  rales  in  both 
backs.  Abdomen  was  slightly  distended,  and  showed  slight  spasm 
and  considerable  tenderness  in  the  right  upper  quadrant,  where  an 
indefinite  mass  could  be  felt  to  move  with  respiration.  There  was 
also  a  tenderness  over  the  pubes.  The  reflexes  were  normal.  Urine 
normal.  Blood  at  entrance  showed  19,000  leukocytes.  Hemoglobin, 
85  per  cent. 

Soon  after  entrance  she  vomited  100  c.c.  of  grayish  fluid,  with  a 
positive  reaction  to  guaiac,  but  no  free  HCl.  This  reaction  was 
present  also  in  the  stools.  Throughout  the  ten  days'  stay  in  the 
medical  wards  (808-241)  the  abdomen  remained  moderately  distended, 
and  despite  the  good  results  of  enemata  and  cathartics  there  was  often 
general  abdominal  pain,  occasionally  crampy.  She  vomited  more  or 
less  each  day,  retaining  liquids  until  about  12  ounces  had  been  taken 
and  then  rejecting  almost  the  entire  amount.  The  temperature  during 
this  period  was  normal,  but  the  pulse  gradually  rose  from  80  to  no. 

Discussion. — Although  this  patient  has  been  habitually  consti- 
pated, we  cannot  attribute  her  present  stomach  trouble  to  that 
cause,  for  the  present  trouble  is  acute,  the  other  chronic. 

We  note  that  this  patient  has  had  a  good  deal  more  pain  than  the 
t5^ical  dyspeptic.     We  note,  also,   that  she  is  at  the  cancer  age. 


DYSPEPSIA  273 

though  we  put  less  stress  upon  this,  in  relation  to  gastric  cancer, 
when  the  patient  has  had  chronic  stomach  trouble,  as  in  the  present 
case. 

In  favor  of  gastric  cancer  we  have  the  presence  of  a  mass  in  the 
right  hj^ochondrium,  with  blood  in  the  stomach,  absence  of  HCl, 
and  stasis.  The  fact  that  she  has  had  no  movement  of  the  bowels 
for  ten  days  makes  it  necessary  to  consider  cancer  of  the  bowel  also. 
It  is  always  to  be  remembered  that  cancer  of  the  bowel  can  reproduce 
almost  all  the  symptoms  of  cancer  of  the  stomach.  The  persistence 
of  crampy  abdominal  pain,  after  she  had  been  put  at  rest  and  had 
had  her  bowels  emptied,  favors  intestinal  neoplasm.  The  condition 
of  the  lungs  shows  a  weak  heart.  The  leukocytosis  is  not  accounted 
for.     No  definite  diagnosis  was  made. 

Outcome  .^December  i8th  the  abdomen  was  opened  and  hard 
masses  found  all  about  the  lower  border  of  the  Hver,  the  gall-bladder, 
and  the  pylorus.  The  abdomen  also  showed  a  number  of  other  hard 
masses,  presumably  in  the  omentum  and  mesentery,  but  no  evidence 
of  intestinal  obstruction  was  found.  After  operation  she  vomited 
less  and  was  more  comfortable,  but  gradually  lost  strength,  and  died 
December  31st.  Autopsy  showed  cancer  of  the  gall-bladder,  with 
extensive  metastases  in  the  neighboring  l)miphatic  glands.  There 
was  also  a  streptococcus  septicemia,  with  a  small  abscess  in  the  right 
lung,  together  with  obsolete  tuberculosis  at  the  apex  of  each  lung 
and  a  moderate  amount  of  arteriosclerosis.  There  is  very  Httle  in 
the  case,  as  we  look  back  over  it,  to  set  us  right  in  diagnosis.  The 
absence  of  jaundice  and  of  any  tumor,  recognizable  as  the  gall-bladder, 
makes  it  difficult  to  see  how  a  correct  diagnosis  could  have  been 
made.  It  is  striking  that  with  a  normal  stomach  and  intestine  such 
marked  gastric  and  intestinal  symptoms  were  nevertheless  present. 
Possibly  the  metastatic  masses  may  have  had  some  connection  with 
this. 

Case  105 

A  housewife  of  forty-eight  entered  the  hospital  December  19,  191 1. 
Her  father  and  grandmother  died  of  "stomach  trouble,"  othermse 
her  family  history  is  good.  Six  years  ago  she  had  some  abdominal 
operation  done  at  the  Homeopathic  Hospital.  The  nature  of  the 
operation  is  not  known,  but  menstruation  has  been  absent  ever  since. 
For  twenty  years  she  has  been  troubled  with  indigestion,  chiefly  a 
form  of  epigastric  distress,  without  apparent  relation  to  meals.  The 
distress  comes  at  irregular  intervals,  and  is  associated  with  nausea 

Vol.  11—18 


2  74  DIFFERENTL^L  DLAGNOSIS 

and  flatulence,  but  not  with  vomiting.  Besides  this  distress  she  has 
several  times  had  attacks  of  very  severe  pain  in  the  epigastrium, 
which  double  her  up  and  need  morphin  for  their  relief.  She  has  never 
been  jaimdiced  and  had  no  fever,  but  she  has  had  a  series  of  chills 
which  often  accompanied  the  epigastric  pain.  The  most  recent  chill 
accompanied  an  attack  of  pain  last  night.  The  urine  has  been  dark, 
the  stools  sometimes  black.  The  last  severe  attack  was  four  weeks 
ago.     As  a  rule,  pain  lasts  about  six  hours. 

The  physical  examination  is  negative,  except  for  rigidity  of  the 
whole  abdomen,  preventing  further  examination.  Tenderness  is 
complained  of  throughout,  but  it  is  not  severe.  It  is  apparently  most 
marked  in  the  right  half  of  the  abdomen,  which  is  tympanitic  and 
level  throughout.  The  blood  and  urine  are  normal;  likewise  the 
pulse,  temperature,  and  respiration. 

Discussion. — What  can  we  infer  from  a  family  history  such  as  is 
present  in  this  case?  Nothing  definite.  The  so-called  stomach 
trouble  from  which  her  father  and  grandfather  died  may  have  been 
uremia,  angina  pectoris,  hepatic  cirrhosis,  pernicious  anemia,  or 
many  other  diseases.  We  have  no  good  reason  j.o  suppose  that  it  was 
really  connected  with  the  stomach. 

The  patient  has  had  twenty  years  of  indigestion,  but  the  striking 
thing  is  that  there  has  been  no  relation  between  this  indigestion 
and  the  taking  of  food.  In  other  words,  there  is  no  good  reason  to 
attribute  the  distress  to  the  stomach  itself.  The  occurrence  of  severe 
pain,  relieved  by  morphin  and  associated  with  chills,  leads  us  to  con- 
jecture that  gall-stones  are  present.  Indeed,  the  chief  difficulty  be- 
fore us  is  to  avoid  jumping  at  the  conclusion  that  it  must  be  gall- 
stones before  we  have  adequately  thought  out  the  other  possibilities. 
The  history  is  certainly  typical  of  gall-stones,  and  the  physical  ex- 
amination also,  since  the  physical  examination  of  most  gall-stone 
cases  reveals  nothing  whatever,  as  in  this  case.  What  else  could  it 
be?  Duodenal  ulcer,  first  of  all,  for  it  is  notorious  that  gall-stones 
and  duodenal  ulcer  may  absolutely  simulate  each  other.  The  pres- 
ence of  gastric  trouble,  between  the  sharp  attacks  of  pain,  is  what  one 
would  expect  with  ulcer.  Against  ulcer,  however,  is  the  absence  of 
any  typical  hunger  pain,  any  definite  relation  to  meals,  or  any  relief 
by  food.  Positive  evidence  of  ulcer,  such  as  blood  or  x-xd^y  findings, 
is  absent,  and  it  is  certainly  unusual  to  meet  with  ulcer  pain  requiring 
morphin  and  promptly  reheved  by  it. 

It  is  now  the  fashion  to  attribute  symptoms  of  this  kind  to  chronic 
appendicitis  and  to  remove  the  appendix  for  their  rehef,  but  it  seems 


DYSPEPSIA  275 

to  me  that  it  is  becoming  more  and  more  difficult  to  defend  this 
standpoint.  The  revelations  of  Dr.  E.  A.  Codman's  paper  on  "Chronic 
Appendicitis"^  are  more  impressive  the  more  thoroughly  we  study 
them.  Personally,  I  do  not  think  there  is  the  slightest  evidence  that 
symptoms  hke  this  patient's  were  ever  produced  by  chronic  appendi- 
citis. 

Renal  colic,  due  to  stone  or  other  causes,  might  produce  such  a 
pain,  but  I  have  never  known  it  to  be  confined  to  the  epigastrium. 
Moreover,  we  have  no  confirmatory  evidence  in  the  urine. 

Outcome. — December  20th  the  abdomen  was  opened  and  the  gall- 
bladder found  to  be  distended.  About  ten  gall-stones,  of  various  sizes, 
were  removed  from  it,  but  none  were  felt  in  any  of  the  ducts.  The 
patient  made  a  good  recovery  and  was  discharged  the  9th  of  January. 
December  16,  1912,  her  family  physician  reported  that  she  is  and 
has  been  perfectly  well. 

Looking  back  over  the  case,  with  the .  operative  findings  in  our 
minds,  have  we  good  reason  to  believe  that  the  patient's  twenty  years 
of  indigestion  were  due  to  the  gall-stones  removed  at  operation  or 
to  other  similar  stones?'  It  is  customary  to  answer  this  question 
in  the  affirmative,  but  I  cannot  see  that  the  custom  has  any  good  basis 
in '  experience.  There  are  plenty  of  patients  who  have  just  such 
indigestion  yet  who  show  postmortem  no  evidence  whatever  of 
gall-stone.     The  association  may  well  be  a  coincidence. 

Case  106 

An  Irish  housewife  of  twenty-three  entered  the  hospital  August 
19,  1909.  Two  months  ago  she  began  to  have  nausea,  vomiting,  and 
headache.  Previous  to  that  she  has  always  been  well,  and  has  a  good 
family  history  except  that  one  sister  died  of  tuberculosis,  nine  years 
ago,  while  living  in  the  same  house  with  the  patient.  Early  in  the 
present  illness  the  vomiting  was  accompanied  by  nausea,  and  oc- 
curred especially  on  rising  in  the  morning.  Later,  it  occurred  more 
generally  through  the  day.  After  three  weeks  of  this  trouble  she  be- 
gan also  to  have  headache,  a  dull  frontal  and  occipital  pain,  with 
frequent  sharp  attacks,  which  have  continued  ever  since.  A  week 
ago  the  sight  of  the  right  eye  began  to  be  dim,  and  now  she  cannot 
distinguish  objects  with  it.  About  the  same  time  she  noticed  slight 
numbness  in  the  left  side  of  the  face  and  occasional  sKght  vertigo. 
Within  the  last  week  she  has  fainted  twice. 

Physical   examination   shows   a   well-nourished   patient,   with   a 

^  Boston  Med.  and  Surg.  Jour.,  October  2,  1913. 


276 


DIFFERENTIAL  DIAGNOSIS 


marked  internal  squint  of  the  right  eye.  The  left  eye  does  not  move 
past  the  median  line  toward  the  left.  Other  movements  are  well 
made.  Pupils  normal.  Choked  disk  in  both  eyes.  Chest  and  ab- 
domen negative.  Slight  dulness  of  sensation,  especially  to  pain,  on 
the  left  side  of  the  face,  neck,  and  upper  arm.  She  cannot  count 
fingers  with  the  right  eye.  The  reflexes  of  the  jaw,  biceps,  wrist,  and 
knee  are  exaggerated.  The  ankle-jerks  not  obtained.  Babinski's 
reflex  is  negative  on  both  sides.     Gordon  and  Oppenheim  positive 

on  the  right  side.  Blood-pres- 
sure, 140  mm.  Hg.  Tempera- 
ture, blood,  and  urine  negative. 

Discussion. — The  age  of  the 
patient  and  the  exposure  to  tuber- 
culosis hint  at  a  dyspepsia  symp- 
tomatic of  that  disease,  but  the 
loss  of  sight  in  one  eye,  the  numb- 
ness about  the  face,  and  the  unex- 
plained fainting  makes  it  pretty 
clear  that  we  must  look  for  some 
deeper  cause  for  the  patient's 
vertigo. 

The  physical  examination 
makes  it  reasonably  certain  what 
this  case  is.  The  choked  disks, 
the  increased  reflexes,  and  pares- 
thesia of  the  focal  type  consti- 
tute a  symptom  complex  pointing 
without  any  considerable  doubt  to  a  circumscribed  intercranial  lesion, 
of  which  the  vastly  most  common  example  is  brain  tumor. 

Syphilis  can  cause  similar  symptoms,  but  we  have  no  definite 
evidence  of  that  disease,  and  double  choked  disk  is  not  common  in  the 
early  stages  of  cerebral  syphilis.  Arteriosclerosis  at  twenty-three  is 
rather  a  far-fetched  surmise.  Tuberculous  meningitis  does  not  pro- 
duce double  choked  disk  and  rarely  presents  such  definite  focal  symp- 
toms.    Brain  tumor  is  the  only  reasonable  diagnosis. 

Outcome. — Operation  August  21st  for  decompression;  the  record 
does  not  state  which  side,  but  apparently  in  the  temporal  region. 
There  was  no  improvement  in  her  condition  after  this  operation,  and 
on  the  nth  of  September  the  same  opening  was  enlarged,  still  with- 
out any  gain.  After  the  23d  of  September  the  patient  ran  a  steady 
fever,  most  of  the  time  above  100°  F. 


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DYSPEPSIA  277 

On  the  9th  of  October  she  died.  Autopsy  showed  glioma  of  both 
frontal  lobes  and  of  the  basal  gangha  on  both  sides.  The  fever  was 
unexplained  (Fig.  100). 

Case  107 

A  fisherman  of  thirty-eight  entered  the  hospital  November  15, 
1909.  Family  history  and  past  history  negative.  For  three  years 
he  has  been  bothered  with  attacks  of  epigastric  soreness  and  disten- 
tion, somewhat  reheved  by  belching.  In  the  intervals  between  these 
attacks  he  is  perfectly  well  and  never  vomits  at  any  time.  During 
one  attack,  three  weeks  ago,  he  thinks  he  was  slightly  jaundiced 
and  had  dark  urine.  His  appetite  is  ravenous.  He  eats  at  irregular 
intervals  and  bolts  his  food.  His  bowels  are  very  constipated.  The 
last  two  attacks  have  been  more  severe  than  usual,  and  pain  has  been 
referred  to  the  back.  In  the  past  three  years  thinks  he  has  lost  5 
pounds. 

Physical  examination  shows  a  marked  funnel  breast,  but  is  other- 
wise negative.  A  stomach-tube  is  passed  and  shows  no  contents  in 
the  fasting  stomach.  The  water  capacity  of  the  organ  is  one  quart. 
After  a  test-meal  the  stomach  contents  show  free  HCl,  0.027  P^r 
cent.;  total  acidity,  0.116  per  cent.  Blood  and  urine  are  normal. 
There  is  no  fever. 

Discussion. — The  patient  has  had  three  years  of  typical  dyspepsia 
in  paroxysms,  with  a  fine  appetite  and  a  marked  constipation.  Phys- 
ical examination  shows  nothing.  Is  the  constipation  in  itself  enough 
to  account  for  the  patient's  symptoms?  If  we  take  it  in  connection 
with  his  bad  dietetic  habits,  I  think  we  can  say  yes.  It  is  not  quite 
certain  whether  the  bad  habits  are  the  cause  of  the  constipation  or 
vice  versa,  but  taken  together  they  should  be  enough  to  upset  his 
digestion.  At  any  rate,  treatment  should  proceed  upon  this  theory 
until  it  is  clearly  disproved. 

This  is  the  sort  of  case  in  which  many  a  surgeon  rushes  in  where 
the  internist  fears  to  tread,  and  it  is  perfectly  possible  that  in  the 
long  run,  after  thorough  study,  an  exploratory  incision  might  be 
justified  in  such  a  case,  but  certainly  not  until  we  have  obtained  reason- 
able assurance  that  the  correction  of  his  symptoms  is  not  all  sufficient. 

Outcome. — He  went  home  November  18,  1909,  seemingly  quite 
well.  November  i,  191 2,  his  family  physician  writes  that  the  patient 
has  been  able  to  work  steadily  since  leaving  the  hospital.  He  still  has 
some  left  epigastric  pain  and  is  badly  constipated,  but  when  he 
keeps  his  bowels  open  he  gets  along  quite  comfortably. 


!78  DIFFERENTIAL  DIAGNOSIS 


Case  108 


A  janitor,  a  negro  of  forty,  entered  the  hospital  November  2, 
1909.  The  patient's  family  history  is  good.  His  wife  has  had  two 
living  children,  followed  by  seven  miscarriages  early  in  pregnancy. 
The  patient  has  been  in  excellent  health,  and,  according  to  his  own 
account,  has  excellent  habits. 

Last  June  he  began  to  have  excessive  flow  of  saliva,  eructations 
with  epigastric  pain,  and  vomiting.  He  had  never  had  any  trouble 
with  his  digestion  before.  His  pain  was  never  severe.  His  vomit- 
ing was  at  first  about  once  a  week,  now  after  almost  every  meal. 
He  ejects  part  of  the  food  eaten,  sometimes  more  than  he  can  account 
for.  The  vomitus  is  always  sour,  never  bloody.  He  is  somewhat 
eased  by  soda.  Recently  he  has  been  getting  weak  and  short  of 
breath  and  has  had  night-sweats.     Since  June  he  has  lost  30  pounds. 

Physical  examination  showed  fair  nutrition,  considerable  loss  of 
flesh.  Pupils  equal,  slightly  irregular,  reacting  normally.  Aortic 
second  sound  much  accentuated — loud,  ringing,  deliberate.  Blood- 
pressure,  260  mm.  Hg.  No  evidences  of  cardiac  enlargement.  Lungs 
and  abdomen  negative.  Blood  negative.  Urine  averaged  40  ounces 
in  twenty-four  hours;  1005  to  1009  in  specific  gravity;  trace  of  al- 
bumin; no  casts. 

The  stomach-tube,  passed  before  breakfast,  showed  some  remains 
of  food  eaten  the  day  before.  Gastric  capacity,  34  ounces.  After 
a  test-meal  HCl  was  absent.  On  the  4th  of  November  the  patient 
began  to  complain  of  nocturnal  headache,  dizziness,  muscular  tremor, 
and  vomiting  of  an  expulsive  character  without  preceding  nausea. 
He  continued  to  vomit  once  or  twice  a  day,  but  in  other  respects 
seemed  somewhat  improved  after  antispecific  treatment  had  been 
stopped  and  purgation  begun.  Examination  of  the  fundus  showed 
exudate  and  hemorrhages  around  each  optic  disk. 

Discussion. — The  chief  features  in  the  history  is  the  occurrence 
of  seven  miscarriages  in  the  patient's  wife,  the  six  months'  salivation, 
epigastric  pain  and  vomiting,  with  a  loss  of  30  pounds  in  weight,  and, 
more  recently,  dyspnea  and  sweating.  This  is  just  the  sort  of  case 
in  which  anyone  who  tries  to  practice  medicine  without  routine 
measurement  of  blood-pressure  will  go  clean  astray.  Without  the 
blood-pressure  measurement  one  might  not  feel  at  all  sure  of  cardiac 
h^-pertrophy,  and  without  that  it  would  be  impossible  to  be  positive 
that  the  patient  has  nephritis.  The  combination  of  the  urinary 
findings,  the  examination  of  the  heart  and  the  blood-pressure  would 


DYSPEPSIA  279 

be  practically  diagnostic  of  nephritis,  even  if  we  did  not  have  the 
retinitis  to  make  certainty  doubly  sure. 

It  is  to  be  noticed  that  the  vomiting  is  distinctly  of  the  cerebral 
type,  the  type  often  associated  with  brain  tumor,  but  more  properly 
associated  with  increase  of  intercranial  pressure,  whether  by  reason 
of  brain  tumor,  h5^pertension,  or  other  causes. 

One  might  easily  have  been  puzzled  in  this  case  if  one  were  in  the 
habit  of  putting  undue  stress  on  the  significance  of  gastric  stasis  and 
achylia.  These  findings  are  often  of  great  importance  when  there  is 
nothing  outside  of  the  stomach  to  account  for  them,  but  only  then 
should  we  think  of  them  as  direct  evidence  of  gastric  disease. 

Outcome. — The  headache  after  the  8th  of  November  was  shght 
and  he  slept  well.  The  vomiting  seemed  to  have  no  relation  to 
eating,  and  on  the  17th  his  relatives  became  alarmed  and  took  him 
home.'    His  blood-pressure  by  this  time  had  fallen  to  200. 

Case  109 

A  married  woman  of  fifty-two  entered  the  hospital  January  10, 
19 10.  Family  history  and  past  history  negative.  Always  subject 
to  sick  headache,  and  thinks  that  fifteen  years  ago  she  had  same 
trouble  as  now.  States  that  she  always  had  "deHcate"  stomach,  but 
no  particular  trouble  with  it  until  the  i6th  of  September,  when  she 
began  to  have  epigastric  pain  and  vomiting.  These  symptoms 
lasted  a  few  days  and  then  she  was  comfortable,  but  there  have  been 
three  similar  attacks  since  December  15th,  and  a  good  deal  of  flatulence 
between  them.  The  epigastric  pain  comes  at  a  variable  time  after 
eating.  Since  the  middle  of  December  her  appetite  has  been  poor 
and  her  bowels  have  needed  laxatives.  She  has  lost  much  strength 
and  considerable  weight.  Her  diet  has  been  mostly  rice,  milk,  Indian 
meal,  and  raw  eggs.  For  the  past  five  days  she  has  not  vomited,  but 
has  been  troubled  a  good  deal  with  vertical  headache.  For  the  past 
four  or  five  years  she  has  passed  urine  twice  each  night  after  bedtime. 

Physical  examination  of  the  chest  was  negative.  General  nutri- 
tion was  good.  Had  a  well-marked  herpes  upon  the  hps.  The  heart's 
apex  was  in  the  fifth  space,  14I  cm.  from  midsternum.  Pulse  of  high 
tension  and  aortic  second  sound  accentuated.  Blood-pressure  not 
measured.  On  right  side  of  the  abdomen  a  hard,  elastic,  insensitive, 
sKghtly  movable  tumor  was  felt,  about  the  size  of  a  grape-fruit. 
It  was  easily  felt  in  the  flank  with  bimanual  palpation  and  did  not 
descend  with  respiration.  It  was  not  fluctuant  and  did  not  seem  to 
be  connected  with  the  Hver.     The  colon  was  inflated  and  the  tympany 


2So  DIFFERENTIAL   DIAGNOSIS 

SO  produced  came  in  front  of  the  tumor.  Urine  and  blood  were 
entirely  normal.  Cystoscopy  by  Dr.  Lincoln  Davis,  January  14th, 
showed  a  normal  bladder.  Indigocarmin  was  excreted  from  the  left 
ureter  in  ten  minutes,  but  none  came  out  of  the  right.  The  ureteral 
catheter,  passed"  into  the  right  ureter,  met  an  obstruction  about 
2  inches  from  the  oriiice.  Dr.  Davis  made  a  diagnosis  of  right  hydro- 
nephrosis, due  either  to  stone  or  a  kink  in  the  ureter.  The  obstruction 
above  referred  to  was  only  partial,  for  a  pressure  over  the  tumor 
caused  a  flow  of  urine  on  that  side.  The  urine  obtained  by  catheter 
from  the  right  kidney  showed  0.06  per  cent,  urea;  that  from  the  left, 
1.5  per  cent.  After  indigocarmin  the  urine  from  the  right  side  was 
pale  greenish;  that  from  the  left,  dark  blue. 

Discussion. — The  history  gives  us  merely  the  knowledge  that  the 
patient  has  had  three  months  of  epigastric  pain  and  vomiting.  Ap- 
parently the  pain  is  not  severe.  There  is  nothing  that  suggests  the 
severity  of  the  average  gall-stone  coHc.  In  addition  to  this,  we  have 
one  month  of  anorexia  and  constipation.  Previous  to  the  physical 
examination,  then,  we  have  nothing  distinctive. 

In  the  internal  viscera,  the  most  important  items  are  the  cardiac 
hypertrophy  and  the  tumor  in  the  right  loin.  The  increase  in  blood- 
pressure  is  also  significant,  though  we  have  no  exact  measure  of  it. 
Turning  attention  to  the  tumor,  it  certainly  occupies  the  position  of 
the  kidney,  and,  from  its  characteristics,  should  be  either  a  neoplasm 
or  a  hydronephrosis.  The  absence  of  fever  and  leukocytosis  is 
against  the  existence  of  a  pus  sac.  The  further  cystoscopic  examina- 
tion leaves  little  doubt  that  we  are  dealing  with  hydronephrosis. 
The  obstructed  ureter  and  diluted  urine  are  characteristic.  There 
can  be  no  reasonable  doubt,  it  seems  to  me,  as  to  the  diagnosis,  but 
why  should  a  hydronephrosis  produce  gastric  symptoms?  As  the 
disease  has,  in  all  probability,  come  on  gradually,  the  other  kidney 
should  have  taken  up  the  renal  function  as  it  diminished  upon  the 
diseased  side.  We  should  not  expect,  therefore,  any  evidence  of 
renal  insufficiency  or  uremia,  especially  as  the  mixed  urine  of  the 
two  sides  presents  apparently  normal  characteristics.  It  is  hard  to 
believe  that  merely  by  pressure  a  hydronephrotic  sac  could  bring 
about  the  gastric  symptoms  of  this  case,  and  I  am  unable  to  answer 
the  question  which  I  have  just  put.  It  is,  however,  a  not  unfamiliar 
fact  that  such  symptoms  are  frequently  associated  with  hydronephro- 
sis, although  the  other  kidney  remains  sound. 

Akin  to  the  same  problem  is  the  question  why  an  operation  does 
good,  and  I  am  unable  to  answer  this  question  any  better  than  the 


DYSPEPSIA  251 

other,  although  I  think  there  is  no  possible  doubt  that  operation  is 
of  benefit. 

Outcome. — January  21st  the  kidney  was  operated  upon  and  found 
to  be  hydronephrotic.  The  pelvis  and  calyces  greatly  dilated,  cortex 
very  thin  and  consisting  mostly  of  fibrous  tissue  and  thickened 
blood-vessels.  The  glomeruli  sclerosed  and  atrophied.  The  cause 
of  the  hydronephrosis  was  not  discovered.  The  hydronephrotic  sac 
was  a  single  one.  After  operation  the  patient  did  very  well,  and 
February  15th  reported  that  she  had  no  symptoms,  but  was  still 
rather  weak. 

Case  110 

A  canvasser  of  forty-five  entered  the  hospital  January  18,  19 10. 
His  family  history,  past  history,  and  habits  not  remarkable.  He 
considered  himself  perfectly  well  until  October,  1909,  when  he  began 
to  notice  an  acid  taste  in  his  throat,  about  three  hours  after  eating. 
This  taste  would  soon  be  followed  by  partly  intentional  vomiting  of  the 
contents  of  the  previous  meal.  This  continued  until  five  weeks  ago, 
when  the  vomiting  ceased.  Since  October  his  appetite  has  been 
failing  and  he  can  now  hardly  taste  his  food.  At  that  same  time  he 
noticed  jaundice  and  pain  in  the  region  of  the  navel,  increased  by 
exertion.  Early  in  November  a  diarrhea  appeared,  and  this  has  re- 
curred whenever  he  is  tired.  He  is  much  troubled  by  flatulence, 
especially  at  night.  The  old  discomfort  two  or  three  hours  after 
eating  and  the  acid  taste  in  his  mouth  still  bother  him,  but  meat  and 
eggs  seem  to  go  as  well  as  any  food  and  his  appetite  is  fair.  Bowels 
now  move  daily.     He  has  lost  20  pounds  since  October. 

Physical  examination  shows  poor  nutrition,  distinct  yellowing  of 
the  skin  and  sclerae,  normal  chest,  general  rigidity  and  tenderness  of 
the  abdomen,  most  marked  in  the  upper  portion.  No  abnormal  dul- 
ness  or  masses.     Liver  and  spleen  not  felt.     Reflexes  normal. 

A  stomach-tube  shows  no  fasting  contents.  On  water-distention 
the  stomach  contains  61  ounces,  its  lower  border  reaching  i  inch 
below  the  navel.  An  hour  after  a  test-meal  nothing  can  be  recov- 
ered. The  stools  always  show  slight  reaction  to  guaiac.  Blood  and 
urine  normal;  no  fever. 

By  examination  in  a  hot  bath  an  indefinite  mass  can  be  felt  in  the 
right  hypochondrium  (Fig.  loi). 

On  the  26th  of  January  I  noted,  "No  gastric  trouble  at  present. 
The  lumps  above  referred  to  does  not  seem  to  be  connected  with  the 
kidney.     It  is  probably  associated  with  the  gall-bladder." 


282 


DIFFERENTIAL   DL\GNOSIS 


Discussion. — The  history  is  not  distinctive,  but  when  taken 
with  the  observed  facts  of  jaundice,  a  large  but  rapidly  emptied 
stomach,  and  a  small  mass  in  the  region  of  the  gall-bladder,  it  seems 
to  me  that  the  recorded  data  point  strongly  toward  gall-bladder 
disease.  The  mass  shown  in  the  diagram  might  perfectly  well  be 
attached  to  the  stomach  or  kidney,  but  we  have  no  gastric  or  renal 
symptoms,  while  we  have  one  definite  liver  symptom,  jaundice. 

If,  then,  we  are  dealing  with  gall-bladder  trouble,  what  is  that 
trouble?  The  lump,  as  described,  does  not  sound  like  a  dilated  gall- 
bladder.    If  it  is  not  a  dilated  gall-bladder,  and  yet  is  connected  with 


1 


TOuwi,  vtry' 
vwov  fl-u  le 
\isxn\)  Slit 
0^   Kovse- 
tKeStnut 


Fig.  loi. — Mass  felt  in  Case  no. 


the  biliary  tract,  it  must,  in  all  probability,  be  cancer.  The  main 
point  to  doubt  is  whether  we  are  right  in  supposing  that  it  is  con- 
nected with  the  gall-bladder  at  all.  It  is  mainly  the  presence  of  jaun- 
dice which  gives  us  the  assurance  on  this  point.  But  suppose  the 
jaundice  was  due  to  some  independent  cause,  such  as  catarrhal  cho- 
langitis, gall-stones,  or  cirrhosis  of  the  liver,  the  palpable  mass  might 
then  be  attached  to  some  other  organ.  It  might  arise  from  the 
pyloric  end  of  the  stomach,  despite  the  absence  of  any  evidence  in- 
criminating that  organ.  On  the  whole,  however,  the  weight  of  evi- 
dence seems  to  be  against  this  theory. 

Outcome. — January  28th  the  abdomen  was  opened.     The  gall- 


DYSPEPSIA  283 

bladder  was  found  much  enlarged  and  tense.  Considerable  greenish 
fluid  was  evacuated;  no  stones  found.  The  second  part  of  the  duode- 
num seemed  to  be  filled  by  a  hard  mass,  and  on  opening  this  a 
cauliflower-like  mass,  about  the  size  of  a  pigeon's  egg,  was  found  in 
the  region  of  the  pancreatic  duct,  with  its  base  in  the  ampulla  of 
Vater.  The  tumor  was  removed.  Microscopic  examination  showed 
it  to  be  a  papillary  adenoma.  After  operation  the  patient  did  very 
well  until  February  ist,  when  he  suddenly  vomited  about  3  pints  of 
altered  blood,  and  had,  at  the  same  time,  a  large  Hquid  movement. 
He  collapsed  and  became  pulseless,  his  extremities  cold.  February 
3d  the  lower  end  of  the  wound  opened  and  there  was  a  profuse  dis- 
charge of  intestinal  contents,  evidently  coming  from  the  upper  bowel. 
AU  fluids  taken  by  mouth  issued  from  this  opening,  and  he  was  unable 
to  retain  food  by  the  rectum.  He  died  February  9th.  Autopsy 
showed  chronic  interstitial  hepatitis  and  the  evidences  of  the  recent 
operation,  together  with  a  duodenal  fistula.  The  presence  of  a 
cirrhotic  liver  was  presumably  a  coincidence.  There  is  no  good 
reason  to  suppose  that  it  had  any  connection  with  the  tumor  which 
was  removed. 

Case  111 

A  married  Russian  Jewess  of  thirty-eight  entered  the  hospital 
May  8,  1910.  Her  family  history  was  negative,  likewise  her  past 
history,  except  that  three  and  a  half  years  ago  she  had  an  attack 
similar  to  the  present  one,  lasting  three  weeks.  Her  menstruation 
has  been  normal  until  seven  weeks  ago.  None  has  been  seen  since. 
Has  had  three  children,  youngest  thirteen  years  old.  No  miscarriage. 
For  seven  weeks  she  has  been  troubled  by  pain  in  the  epigastrium 
and  by  vomiting.  Now  she  can  retain  no  food,  and  vomits  imme- 
diately after  eating.  Pain  is  sharp,  but  does  not  radiate.  The  kind 
of  food  makes  no  difference.  She  has  never  vomited  blood.  She  has 
lost  15  to  20  pounds  in  weight. 

Physical  examination  shows  emaciation,  moderate  pallor,  normal 
pupils  and  gums.  Heart's  apex  not  seen,  but  felt  in  the  fifth  space, 
18  cm.  from  midsternum  in  the  nipple  fine.  Right  border,  4  cm. 
from  midsternum.  The  sounds  are  regular  and  of  good  quality,  no 
murmurs.  Abdomen  and  reflexes  normal.  Gastric  examination 
shows  a  stomach  capacity  of  32  ounces,  the  position  of  the  organ  being 
as  in  Fig.  102.  There  is  no  food  residue  before  breakfast.  The  test- 
meal  was  so  largely  disposed  of  at  the  end  of  an  hour  that  nothing 
of  importance  was  recovered.     In  the  wash-water  free  HCl  is  present. 


284 


DIFFERENTLA.L   DIAGNOSIS 


The  blood  and  urine  are  normal.  Blood-pressure,  115.  No  fever. 
Ten  examinations  of  the  stools  in  two  weeks  show  nothing  remark- 
able. Guaiac  reaction  always  negative.  Wassermann  reaction  is  also 
negative. 

Vaginal  examination  showed  uterus  enlarged,  about  the  size  of  a 
three  months'  pregnancy,  and  displaced  decidedly  to  the  right.  On 
the  surface  of  the  fundus  several  nodules  can  be  felt.  She  ceased 
vomiting  on  the  29th  and  went  home  June  3d  in  very  good  condition, 
though  she  had  lost  i^  pounds  since  entering  the  hospital. 


Fig.  102. — Position  of  the  stomach  in  Case  iii. 


Discussion. — This  is  a  case  of  obstinate  vomiting  associated  with 
absent  menses,  and  apparently  with  displacement  of  the  heart's  apex 
to  the  left.  The  latter  finding  suggests  cardiac  hypertrophy  and 
possibly  uremia  as  the  basis  for  the  dyspepsia,  but  the  low  blood- 
pressure  and  normal  urine  make  this  improbable  and  the  results  of 
pelvic  examination  give  us  a  much  more  plausible  hint. 

In  view  of  the  negative  results  of  gastric  and  intestinal  investiga- 
tion, there  is  every  reason  to  beHeve  that  pelvic  tumor  is  the  cause  of 
the  patient's  symptoms.  That  tumor  might  be  a  fibromyoma,  ovarian 
cyst,  or  a  pregnant  uterus.  The  other  possibilities  are  too  rare  to  need 
discussion.     A  fibroid  or  a  cyst  would  be  less  likely  to  be  associated 


DYSPEPSIA 


285 


with  vomiting  and  amenorrhea.  The  most  reasonable  supposition, 
therefore,  is  that  we  are  deahng  with  a  case  of  vomiting  of  pregnancy. 
Outcome. — The  patient  was  visited  January  7,  19 14,  and  said 
that  a  son  was  born  to  her  in  the  autumn  of  1910.  She  has  since 
had  another  child  and  is  perfectly  well,  though  she  looks  sixty  rather 
than  forty. 

Case  112 

A  laborer  of  forty-nine  entered  the  hospital  April  26,  1910.  His 
family  history  was  good.  He  states  that  he  had  lung  fever,  typhoid 
fever,  intermittent  fever,  and  pleurisy,  one  right  after  the  other, 


Fig.  103. — Physical  signs  in  Case  112. 


when  very  young.  Otherwise  he  has  been  well,  except  that  for  the 
past  eight  years  he  has  had  a  little  stomach  trouble,  which  he  did  not 
notice  enough  to  give  a  clear  description  of  until  February  26,  1910, 
when  he  began  having  sharp  pains  in  the  pit  of  his  stomach  and  right 
hypochondrium,  coming  at  any  time  of  day  without  relation  to  meals 
or  kind  of  food.  He  also  had  spells  of  vomiting  three  to  five  hours 
after  a  meal,  the  act  usually  relieving  him.  He  never  vomited  large 
amounts  at  one  time,  nor  recognized  any  blood  or  any  substance  eaten 
the  day  before.  The  pain  which  immediately  precedes  vomiting  is 
very  sharp  and  "cuts  his  wind."     He  now  vomits  three  or  four  times 


286  DIFFERENTIAL  DIAGNOSIS 

a  week.  His  bowels  have  always  been  very  costive,  and  he  has  once 
gone  twelve  days  without  a  movement.  Nevertheless,  his  appetite 
has  remained  good.  Since  February  he  thinks  he  has  lost  40  pounds 
and  has  been  practically  unable  to  work.  He  uses  no  alcohol  and  is 
generally  a  man  of  exemplary  habits. 

Physical  examination  was  negative  except  for  slight  rigidity  of 
the  whole  abdomen.  Preliminary  diagnosis  was  malignant  disease  of 
the  stomach  or  intestines.  Stomach  examination  showed  a  capacity 
of  56  ounces  (Fig.  103),  but  no  fasting  contents,  and  a  motihty  so 
active  that  an  hour  after  test-meal  there  could  be  nothing  recovered. 
Free  HCl,  however,  was  present  in  the  wash-water.  May  ist  he  had 
some  spasm  and  slight  tenderness  in  the  region  of  the  cecum  and 
above  it.  He  was  eating  well  and  had  vomited  but  once  since 
entrance.  Examination  of  a  stool  by  Dr.  W.  F.  Boos  showed  about 
i|  mg.  of  lead  calculated  as  lead  sulphate.  The  blood  showed  no 
stippling  or  achromia  and  was  in  all  respects  negative,  as  was  the 
urine.  No  elevation  of  pulse,  temperature,  or  respiration.  Systolic 
blood-pressure,  130.  Ten  examinations  of  the  feces  in  three  weeks 
were  uniformly  negative  to  guaiac.  During  most  of  his  stay  in  the 
hospital,  which  ended  May  21st,  he  was  comfortable  and  his  weight 
increased  2I  pounds.     No  source  of  lead-poisoning  was  discovered. 

Discussion. — The  loss  of  40  pounds  of  weight  in  two  months  with 
epigastric  pain  and  vomiting  in  a  laborer  of  forty-nine  suggest  espe- 
cially a  gastric  cancer,  gall-stones,  and  tabes  dorsalis.  Uremia  is  also 
to  be  considered. 

The  results  of  physical  examination  enable  us  to  exclude  all  of  these 
possibilities  with  reasonable  certainty,  although  it  is  conceivable  that 
his  trouble  may  have  been  tabes,  as  no  spinal  puncture  was  done. 
The  finding  of  lead  in  the  stool  does  not  seem  to  me  altogether  con- 
clusive evidence  that  the  patient's  sufferings  were  due  to  lead-poison- 
ing, since  we  have  no  possible  inkling  as  to  the  source  of  any  lead  and 
no  other  symptoms  characteristic  of  lead-poisoning.  I  have  no 
better  diagnosis  to  suggest,  but  do  not  feel  at  all  certain  that  we  have 
hit  upon  the  real  nature  of  the  man's  trouble. 

Outcome. — Three  and  one-half  years  later,  in  the  autumn  of  1913, 
the  patient  was  perfectly  well.  This  excludes  tabes,  but  does  not 
settle  the  question  of  diagnosis  in  any  positive  way.  If  he  had  lead- 
poisoning,  why  should  his  symptoms  have  ceased,  since  we  have  dis- 
covered no  source  whence  he  might  have  absorbed  lead? 


DYSPEPSIA  287 


Case  113 


A  billiard  clerk  of  fifty-nine  entered  the  hospital  June  2,  1910. 
Until  March  ist  of  that  year  he  was  perfectly  well,  when  he  began  to 
have  dyspepsia  and  severe  constipation,  followed  later  by  diarrhea 
and  considerable  loss  of  weight.  SoUd  food  caused  nausea  and  dis- 
tress, followed  by  vomiting.  He  has  never  vomited  blood  or  large 
amounts  of  any  material.  He  has  had  no  severe  pain.  He  has  hved  on 
cocoa,  rice,  milk,  and  eggs,  and  has  eaten  as  much  as  he  wanted,  yet 
in  the  past  three  months  has  lost  27  pounds.  The  bowels  are  regular 
and  he  had  never  seen  any  tarry  stools.  For  the  past  month  he  has 
not  worked  on  account  of  weakness.     He  has  had  no  other  symptoms. 

On  physical  examination  he  was  poorly  nourished  and  showed  evi- 
dent loss  of  flesh.  Over  his  chest,  shoulders,  and  back  were  many 
irregular,  raised,  scaly  areas,  bright  yellow  to  brown  in  color,  and 
from  I  to  I  inch  across.  They  were  papular  or  fiat,  sometimes  verru- 
cose.  The  pupils  and  gums  were  normal.  He  had  practically  no 
teeth.  The  left  tonsil  showed  an  excrescence,  size  of  a  pea ;  no  exudate. 
There  were  a  few  inguinal  lymph-nodes,  the  size  of  large  beans. 

The  heart,  vessels,  and  blood-pressure  showed  nothing  abnormal, 
except  that  the  arteries  were  thickened  and  beaded.  At  the  base  of 
the  left  lung  the  breathing  was  somewhat  diminished  and  there  was  a 
slight  dulness;  otherwise  the  lungs  were  negative. 

In  the  left  loin  a  mass  corresponding  to  the  position  of  the  left 
kidney  was  palpable.  There  was  no  tenderness  and  no  movement 
with  respiration;  otherwise  the  abdomen  was  normal,  likewise  the 
remainder  of  the  physical  examination,  including  temperature,  pulse, 
and  respiration.  The  urine  averaged  25  ounces  in  twenty-four 
hours,  with  a  specific  gravity  1015  to  1020.  It  contained  from  o.i 
to  0.3  per  cent,  of  albumin  and  a  sediment  of  pure  pus  from  50  to  120 
c.c.  in  a  urine-glass  containing  5  ounces.  One  centimeter  of  this 
sediment  injected  into  a  guinea-pig  June  5th.  Six  weeks  later  the 
animal  was  killed;  autopsy  showed  nothing.  Half  a  centimeter  of  the 
urine  collected  under  aseptic  precautions  was  planted  on  appropriate 
culture-media  and  found  to  contain  a  pure  culture  of  Staphylococcus 
aureus.  The  pus  was  present  in  the  urine  intermittently,  some 
specimens  being  quite  clear  of  it. 

Cystoscopy  by  Dr.  Lincoln  Davis  showed  normal  bladder,  with  a 
slight  intravesical  projection  of  the  prostate.  From  the  left  ureter, 
which  appeared  normal,  there  issued  at  regular  intervals  a  stream  of 
thick  pus.     Clear  urine  came  from  the  right.     Stomach  examination 


288  DIFFERENTIAL   DLA.GNOSIS 

showed  no  fasting  contents  and  no  reaction  to  guaiac.  After  a  test- 
meal,  free  HCl,  0.09  per  cent.;  total  acidity,  0.2  per  cent. 

During  his  two  weeks'  stay  in  the  medical  ward  the  patient  seemed 
comfortable,  complained  of  nothing,  lost  5  pounds,  but  subsequently 
regained  it. 

Discussion. — This  man  has  no  teeth,  but  as  he  has  gotten  along 
without  them  for  fifty-eight  years,  more  or  less,  it  is  not  probable  that 
their  absence  would  suddenly  begin  to  produce  such  severe  symptoms 
as  are  now  troubhng  him. 

He  is  at  the  cancer  age,  and,  unless  evidence  of  other  disease  is 
positive,  one  must  certainly  consider  gastric  neoplasm. 

The  mass  in  the  loin,  when  considered  with  the  pyuria,  which 
is  of  the  intermittent  (that  is,  the  renal)  type,  leaves  little  doubt  that 
the  patient  has  a  pyonephrosis.  The  negative  guinea-pig  test 
excludes  tuberculosis  with  practical  certainty.  Cystoscopy  confirms 
what  was  reached  as  the  result  of  other  methods  of  examination,  and 
the  negative  results  of  stomach  tests  further  reassure  us  with  regard 
to  that  organ.  It  remains  somewhat  mysterious  that  the  patient  has 
no  fever.  But  for  the  presence  of  pus  in  the  urine,  we  might  suppose 
that  we  were  dealing  with  a  hydronephrosis. 

From  the  condition  of  the  patient's  arteries  we  may  assume  that 
he  also  has  arteriosclerosis,  but  there  is  no  reason  to  believe  that  this 
is  connected  with  his  present  suffering. 

Outcome. — June  20th  Dr.  F.  G.  Balch  cut  down  upon  the  left 
kidney,  which  consisted  only  of  a  pus  sac,  containing  large  quantities 
of  dark  reddish  pus  and  blood.  Two  or  three  large  rough  calculi  were 
found  in  the  sac.  Attempts  to  ligate  the  pedicle  were  useless  on 
account  of  its  infiltration.  Histologic  examination  of  the  mass  showed 
a  kidney  16  by  8  by  6  cm.,  the  wall  consisting  of  fibrous  tissue,  with 
occasional  remains  of  tubules  and  glomeruli.  One  of  the  calculi 
removed  in  the  sac  measured  4  by  i|  cm.  No  evidence  of  tuberculosis 
was  found.  The  patient  gained  rapidly  after  operation  and  was  dis- 
charged July  6,  1910,  to  the  Waverly  Convalescent  Home,  the  wound 
not  quite  healed.  November  7,  191 2,  he  reported  that  he  had  been 
perfectly  well  for  over  two  years. 

Case  114 

A  clerk  of  twenty-seven  entered  the  hospital  June  13,  1910.  His 
family  history,  past  history,  and  habits  were  not  remarkable.  Three 
years  ago  he  began  to  have  "water-brash"  and  nausea,  coming  on  at 
any  time  without  relation  to  food.     He  is  sometimes  free  from  it  for 


DYSPEPSIA  289 

three  weeks  at  a  time,  but  in  the  past  two  years  his  troubles  have  been 
aggravated,  and  there  have  been  occasional  attacks  of  vomiting  and  of 
dull  pain  in  the  epigastrium,  which  attacks  make  him  feel  like  lying 
down.  At  the  present  time  he  usually  vomits  twice  or  thrice  daily 
and  has  no  appetite. 

Formerly  he  ate  a  good  deal  of  candy,  hurried  through  his  meals, 
chewed  them  very  little,  and  took  them  at  very  irregular  hours. 
While  in  Ireland,  a  year  ago,  on  a  vacation,  he  lived  upon  simple  food 
and  had  no  trouble.  For  the  past  two  years  his  bowels  have  needed 
laxatives.  He  has  worked  steadily  up  to  entrance.  His  best  weight 
was  135  pounds;  now  he  weighs  112  pounds. 

Physical  examination  shows  poor  nutrition,  no  teeth  upon  the 
upper  jaw,  negative  chest  and  abdomen,  normal  reflexes,  blood-press- 
ure 100,  normal  urine  and  blood.  Four  examinations  of  the  feces 
showed  a  positive  guaiac  test  but  once,  when  streaks  of  fresh  blood 
were  visible  in  the  sediment.  A  stomach  examination  showed  no 
contents  in  the  fasting  organ  and  no  enlargement.  After  a  test-meal 
the  percentage  of  free  HCl  was  0.09  per  cent.;  total  acidity,  0.17  per 
cent.  He  remained  two  weeks  in  the  ward,  taking  at  first  nothing 
but  water  by  mouth,  and  undergoing  a  good  cleaning  out  of  the 
bowels  with  magnesium  sulphate  and  calomel.  Twenty-four  hours 
later  he  was  fed  on  milk  and  toast,  with  gastric  lavage  daily  before 
breakfast  and  sodium  bicarbonate  when  needed  for  gastric  distress. 
On  the  20th  of  June  he  was  taking  all  liquids  and  soft  solids,  and  on 
the  2ist,  house  diet. 

Discussion. — We  do  not  know  whether  the  23  pounds  which  this 
patient  has  lost  left  him  gradually  or  suddenly.  The  patient's  poor 
condition  is  the  most  important  fact  in  his  case,  and  makes  us  hesitate 
somewhat  to  attribute  his  symptoms  to  his  dietetic  habits  and  the  lack 
of  any  upper  teeth.  Physical  examination,  including  the  investiga- 
tion of  the  stomach,  is  practically  negative.  The  single  positive 
guaiac  test  is  of  no  importance.  Doubtless  his  constipation  aggra- 
vates his  other  troubles,  and,  if  no  deeper  cause  can  be  found,  we  may 
be  content  to  beheve  that  a  reform  of  his  habits  will  cure  him. 

Many  such  cases,  however,  turn  out  later  on  to  have  tuberculosis, 
lead-poisoning,  or  some  extra  gastric  cause  for  their  complaints.  The 
decision  must  rest  upon  the  results  of  treatment  and  the  subsequent 
course  of  the  case. 

Outcome. — June  25, 1910,  he  had  gained  2^  pounds  and  was  practi- 
cally comfortable,  and  that  day  he  was  discharged.  August  2,  1914, 
he  writes  that  he  is  still  troubled  with  dyspepsia,  but  is  at  work. 

Vol.  n— 19 


290 


DIFFERENTIAL   DIAGNOSIS 


Case  115 


A  clergyman  of  sixty-one  entered  the  hospital  June  13,  1910, 
stating  that  in  March,  19 10,  he  had  overworked  and  "his  stomach 
struck  for  higher  pay,"  causing  flatulence  and  sourness  usually  after 
meals,  relieved  for  about  an  hour  by  eating  more  food  or  by  taking  hot 
water  with  a  half-teaspoonful  of  soda.  This  medicine  caused  the 
escape  of  gas.  His  pains  have  never  radiated  and  have  been  diffused 
in  different  parts  of  the  abdomen.  He  has  never  previously  had  any 
acute  attacks  of  abdominal  pain,  and  until  the  present  time  has 
been  absolutely  free  from  nausea  and  vomiting. 

Aside  from  the  symptoms  just  described,  he  is  also  troubled  by 
weakness.  He  has  hved  the  last  two  months  on  Hquids  and  soft 
solids. 

Three  weeks  ago  he  noticed  a  slight  yellowing  of  his  eyes  and 
the  darkening  of  the  color  of  his  urine,  while  his  stools  became  lighter 
colored,  though  daily  movements  occurred.  He  gave  up  work  two 
weeks  ago  and  has  been  in  bed  since.  He  thinks  he  has  lost  10 
pounds. 

Physical  examination  shows  marked  jaundice  and  emaciation. 
The  pupils  are  slightly  irregular  and  do  not  react  to  hght  or  distance. 
There  is  a  lymph-gland,  the  size  of  a  bean,  at  the  angle  of  the  left 
jaw.  Chest  is  negative.  Liver  dulness  extends  from  the  fifth  rib  in 
the  nipple  line  to  a  point  three-fingers'  breadth  below  the  ribs, 
where  a  sharp,  irregular,  nodular  edge  can  be  felt  (Fig.  104).  Spleen  is 
not  palpable.  Knee-jerks  are  sluggish.  Plan  tars  normal.  No  edema. 
Except  for  the  presence  of  bile,  his  urine  is  normal;  Hkewise  his  blood, 
the  coagulation  time  seeming  to  be  unusually  short.  Wassermann 
reaction  was  negative.  Stomach  examination  showed  a  content  of 
54  ounces  and  no  evidence  of  stasis.  On  inflation  the  lower  border 
extends  two  and  a  half  Angers  below  the  navel.  After  a  test-meal 
the  percentage  of  free  HCl  was  0.07;  total  acidity,  0.16. 

He  stayed  two  weeks  in  the  medical  wards,  suffering  no  pain  and 
seeming  generally  comfortable.  His  jaundice,  stools,  and  urine  re- 
mained the  same.  Stools  always  clay  colored.  The  condition  of  the 
belly  is  seen  in  Fig.  104. 

Discussion. — Previous  to  the  appearance  of  jaundice  and  emacia- 
tion— that  is,  during  the  first  two  or  three  months  of  his  illness — 
I  see  nothing  in  the  history  of  this  case  to  tell  us  what  is  the  matter. 
Our  first  thought  would  naturally  be  cancer  of  the  stomach  because 
of  the  sudden  appearance  of  gastric  symptoms  in  a  man  of  sixty-one. 


DYSPEPSIA 


291 


I  do  not  see  that  we  could  have  done  better  than  a  guess  until  the 
jaundice  appeared. 

Besides  cancer  another  guess  previous  to  the  appearance  of  the 
jaundice  would  have  been  tabes,  as  presumably  at  that  time,  as  well 
as  in  June,  the  pupils  failed  to  react  to  light  and  the  knee-jerks  were 
sluggish.  The  gastric  disturbances  are  a  good  deal  less  intermittent 
and  paroxysmal  than  those  traditionally  associated  with  tabes,  but, 
as  I  have  already  stated,  this  tradition  is  by  no  means  a  reliable  one, 
and  any  sort  of  stomach  trouble  associated  with  evidence  of  tabes 
should  be  assumed  to  be  due  to  that  trouble  until  proved  to  the  con- 
trary. 


Fig.  104. — Palpable  mass  as  described  in  Case  115. 


With  the  appearance  of  jaundice  and  emaciation,  our  attention 
is  naturally  drawn  to  the  liver  or  gall-bladder  as  the  probable  source 
of  the  trouble.  The  nodular  mass  in  the  region  of  the  gall-bladder  is 
necessarily  another  alarming  fact.  But  for  that  one  might  imagine 
that  gall-stones  were  the  root  of  his  trouble,  for  emaciation  as  well  as 
jaundice  may  be  marked  in  gall-stone  obstruction  of  the  bile-ducts 
and  pain  is  not  a  necessary  symptom  of  such  obstruction.  But  the 
absence  of  fever  or  any  waxing  and  waning  of  the  jaundice  is  evi- 
dence against  stone  in  the  common  duct,  and  if  the  stone  were  else- 
where jaundice  would  be  unusual. 

If  the  observation  of  a  nodular  mass  be  taken  as  correct,  one 


292  DIFFERENTIAL  DIAGNOSIS 

cannot  well  suppose  that  the  diagnosis  is  gall-stones.  The  patient's 
best  hope  rests  in  the  possibility  that  this  observation  may  be  mis- 
taken, and  that  the  supposed  mass  might  be  nothing  but  an  enlarged 
gall-bladder  or  the  edge  of  a  distended  liver.  The  probabilities  all 
point  to  cancer  in  or  about  the  gall-bladder.  This  cancer  may  be 
secondary  to  a  similar  growth  in  the  stomach  or  may  be  primary  in  the 
biHary  passages. 

Outcome. — He  lost  weight  steadily  and  went  home  on  the  25th, 
diagnosis  being  malignant  obstruction  of  the  bile-duct.  On  the  6th 
of  July  he  returned  for  operation,  which  was  performed  by  Dr.  F.  G. 
Balch.  The  gall-bladder  was  found  moderately  distended  with  a 
thick  greenish  pus,  about  4  ounces  in  amount,  and  contained  no  bile. 
A  stone,  size  of  a  robin's  egg,  was  found  low  down  in  the  gall-bladder, 
close  to  the  duct.  It  was  removed.  The  entire  course  of  the  common 
duct  showed  infiltration  and  suggested  a  malignant  process.  After 
operation  he  improved  slowly,  but  his  stools  still  remained  very 
light  and  his  urine  dark,  always  containing  bile.  On  the  25th  of  July 
he  went  home.  During  the  summer  he  was  tapped  five  times  for  the 
rehef  of  ascites.  The  presence  of  ascitic  fluid  previous  to  these  tap- 
pings seemed  to  produce  most  of  the  discomfort  which  he  experienced. 
Emaciation  and  cachexia  were  progressive.  He  died  November  7, 
1 9 10.  It  is  notable  that  even  at  operation  the  surgeon  was  not  per- 
fectly sure  that  the  stone  found  in  the  common  duct  was  not  the 
whole  cause  of  the  illness.  He  suspected  a  malignant  process,  but  he 
was  not  sure  of  it.  The  patient's  steady  downfall,  despite  the  removal 
of  the  stone,  and  especially  the  fact  that  ascites  accumulated  repeat- 
edly, proves  beyond  reasonable  doubt  that  the  trouble  was  cancerous, 
and  that  it  later  spread  into  the  abdominal  glands  so  as  to  block  the 
portal  circulation. 

It  seems  to  me  a  point  of  great  interest,  as  we  look  back  over 
this  case,  that  although  the  stomach  was  presumably  free  from  any 
disease,  the  only  symptoms  in  the  earlier  months  of  the  illness  were 
dyspeptic  symptoms.  These  were  not  due  to  jaundice,  and  I  do  not 
know  how  they  are  to  be  explained.  The  association  of  such  symp- 
toms with  malignant  disease  of  the  gall-bladder  has  often  been  ob- 
served, but  never,  so  far  as  I  know,  elucidated. 

Case  116 

A  factory  hand  of  twenty-three  entered  the  hospital  June  17,  1910, 
stating  that  two  nights  ago  he  ate  some  hashed  ham  and  pickles  at 
supper,  and  that  about  midnight  he  was  seized  with  sharp,  colicky 


DYSPEPSIA  293 

pain  in  the  abdomen.  The  pain  did  not  radiate,  and  was  somewhat 
relieved  by  pressure  and  by  vomiting.  He  has  continued  to  vomit 
since,  mostly  brown  stuff.  Last  night  his  pains  ceased.  He  has  had 
green  slimy  movements  of  the  bowels.  This  morning  his  stomach 
was  washed  out,  and  since  then  he  has  felt  better  and  is  hungry. 

Physical  examination  negative  except  for  rigidity  of  the  abdomen. 
Slight  spasm  throughout  and  dulness  in  the  flanks,  which  shifted 
freely  with  change  of  position.  He  ran  a  slight  fever,  99°  to  100°  F., 
until  the  21st.  For  the  week  following  that  date  he  was  afebrile.  At 
entrance  his  white  cells  were  24,000,  showing  polynuclear  leuko- 
cytosis. Next  day  the  leukocytes  were  10,000.  The  blood  otherwise 
negative,  likewise  the  feces.  Systolic  blood-pressure,  140.  On  the  28th 
he  seemed  entirely  well  and  had  no  physical  signs  of  disease.  His 
vomitus  at  the  time  of  entrance  was  brownish  and  had  strong  reaction 
to  guaiac.  His  treatment  was  starvation  for  twenty-four  hours,  and 
then  small  feedings  of  simple  ingredients.  He  gained  2  pounds 
during  his  ten  days'  stay  in  the  hospital. 

Discussion. — The  history  starts  out  in  this  case  like  an  acute 
gastric  upset  due  to  indiscretion  in  diet,  but  when  physical  examina- 
tion revealed  abdominal  rigidity  and  leukocytosis,  with  shifting  dul- 
ness in  the  flanks  and  a  fever  running  to  100°  F.,  it  certainly  looked 
as  if  something  more  serious  was  going  on.  Peritonitis  has  often  been 
diagnosed  on  slighter  grounds  than  these,  especially  with  a  brownish 
guaiac  positive  vomitus. 

But,  to  my  mind,  all  such  possibihties  are  negatived  by  the  prompt 
improvement  within  twenty-four  hours;  also  by  the  fact  that  the 
patient  is  hungry  and  that  his  leukocytosis  promptly  fell.  I  do  not 
see  how  we  can  attribute  any  serious  disease  to  a  patient  whose  troubles 
clear  up  so  rapidly. 

Just  what  was  the  nature  of  his  attack  I  do  not  know.  Something 
checked  his  digestion  and  started  him  vomiting.  Gastric  crises  in 
tabes  may  begin  in  just  this  way,  but  we  have  absolutely  no  evidence 
of  that  disease,  and  the  course  of  the  trouble,  as  shown  in  the  outcome, 
makes  this  very  improbable.  The  case  seems  to  me  of  great  interest, 
as  showing  how  many  serious  signs  may  be  present  in  an  acute  gastric 
upset,  which  yet  disappears  within  twenty-four  hours.  I  take  it  that 
the  observation  of  shifting  dulness  in  the  flanks  need  not  necessarily 
be  incorrect,  but  probably  was  due  to  the  shifting  of  intestines  dis- 
tended with  fluid  feces. 

Outcome. — In  November,  191 2,  a  friend  reported  that  he  was  in 
perfect  health. 


294  DIFFERENTIAL  DIAGNOSIS 

Case  117 

A  cook  of  twenty-nine  entered  the  hospital  June  15,  1910,  for  the 
third  time.  One  sister  died  of  consumption,  nineteen  years  ago; 
family  history  otherwise  not  remarkable.  November,  1902,  she  was  in 
bed  for  three  weeks  with  a  sharp  epigastric  pain  and  vomiting,  the 
latter  persisting  until  she  entered  the  Boston  Cit\'  Hospital,  Decem- 
ber, 1902.  While  there  she  once  vomited  a  pint  of  blood.  She 
remained  under  treatment  at  the  hospital  until  February,  1903,  but 
still  vomited  daily  at  the  time  of  her  discharge.  During  her  stay  in 
the  City  Hospital  she  was  on  rectal  feeding  for  three  weeks,  but  has 
been  no  better  since  discharge. 

March  31,  1903,  she  entered  the  Massachusetts  General  Hospital, 
complaining  of  five  months'  suffering  with  sharp  pain  in  the  epigas- 
trium, often  lasting  all  night  and  accompanied  by  tenderness  of  the 
abdomen.  Such  attacks  occurred  frequently,  often  many  times  a 
day,  lasting  about  ten  minutes  each.  After  about  three  weeks  in  bed 
these  pains  gradually  ceased,  but  a  few  days  after  getting  up-  again 
she  began  to  have  chills  every  morning  and  vomited  everything  that 
she  ate;  yet  the  previous  pains  did  not  return.  For  the  ten  days  pre- 
vious to  March  31,  1903,  she  vomited  even  small  amounts  of  milk 
and  lime-water,  and  had  a  good  deal  of  burning  pain  after  the  attacks. 
In  the  week  before  entrance  the  vomitus  had  contained  material 
resembling  coffee-grounds.  For  the  same  period  she  had  also  a  slight 
cough,  with  frequent  attacks  of  spasm  of  the  glottis,  lasting  a  few 
moments.  On  a  few  occasions  she  has  had  moderate  sweating  at 
night,  and  for  the  past  two  months  moderate  frequent  headache. 
Has  not  menstruated  since  December  4th. 

At  this  time  physical  examination  showed  considerable  spasm  of 
the  left  rectus  near  the  ribs,  with  tenderness,  but  no  other  abnor- 
mality, except  a  slight  elevation  of  temperature,  usually  99!°  or 
99 1°  F.,  during  the  whole  twenty-four  hours,  with  an  occasional 
fall  to  normal.  This  persisted  during  the  twelve  days  of  her  stay 
in  the  hospital.  Her  pain  was  relieved  by  soda,  and  after  April  2d 
she  had  no  vomiting.  She  developed  a  good  appetite  during  the 
period  of  rectal  feeding,  which  lasted  until  the  nth  of  April;  then  her 
friends  decided  to  take  her  home. 

She  was  not  seen  again  for  five  years,  when  she  re-entered  the 
hospital  July  18,  1908,  stating  that  after  her  last  hospital  treat- 
ment the  vomiting  persisted,  occurring  at  least  once  a  day.  About 
a  year  after  leaving  the  Massachusetts  General  Hospital  she  had  a 


DYSPEPSIA 


295 


gastro-enterostomy  done  at  the  Boston  City  Hospital.  Four  weeks 
later  she  was  again  operated  upon;  six  weeks  after  that,  again, 
and  six  weeks  later,  still  again,  for  adhesions.  Again,  later,  she 
was  subjected  to  still  a  fifth  operation  at  St.  Elizabeth's  Hospital, 
also  for  adhesions.  Since  that  time  she  has  vomited  three  to  six  times 
a  day  a  sour,  green  fluid,  mixed  with  unchanged  food.  She  has  had 
no  pain,  but  a  distress  which  is  relieved  by  vomiting.  Her  bowels 
have  moved  only  with  enema.  She  has  a  dull,  constant  pain  in  the 
right  flank  and  right  lower  quadrant.  When  she  walks  she  has  a  pull- 
ing sensation  near  the  navel.      Despite  all  this  suffering  her  appetite 


TO  enterostomy, 
c\ose6  by  Th'i'b 
0  ^e  T  aT  i  0  n . 


IM 


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>  o 


le  |UY\05tom  y. 

^o\v\t^  at  wVv\eU 
iw  evi  Ji-TO-e.YiS 
la'atOYvioEjie.  was 
ynct-St,. 


Fig.  105. — The  solid  lines  show  the  course  of  the  bowel  as  found  at  the  sixth  operation. 
The  dotted  lines  show  the  new  course  made. 


has  remained  good.  Her  best  weight  was  135  pounds  six  years  ago. 
Last  winter  she  weighed  120  pounds. 

At  this  time  her  chief  complaint  was  still  of  vomiting.  The 
vomitus  always  contained  bile  and  often  pancreatic  juice;  i.  e.,  10  c.c. 
of  vomitus  plus  5  c.c.  of  0.05  per  cent.  NaCO,,  digests  egg-albumin. 
At  none  of  the  operations  was  any  ulcer,  scar,  or  evidence  of  organic 
disease  found.  The  patient's  sister  says  that  she  eats  well  and  only 
vomits  a  little  "off  the  top." 

On  examination  the  patient  was  well  nourished,  and,  aside  from 
tenderness  in  the  region  of  her  numerous  scars,  showed  nothing 
abnormal. 


296 


DIFFERENTIAL  DIAGNOSIS 


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July  20th  the  abdo- 
men was  opened  for  the 
sixth  time  with  consider- 
able difficulty,  the  omen- 
tum being  found  adherent 
in  many  places  to  the 
anterior  abdominal  wall. 
The  gastro-enterostomy 
was  found  in  good  condi- 
tion and  freely  admitted 
the  tips  of  two  fingers.  A 
jejunojejunostomy,  about 
8  inches  below  the  stom- 
ach, was  likewise  found 
in  good  condition.  The 
pylorus  was  found  to  be 
patent.  The  old  gastro- 
enterostomy wound  in  the 
stomach  was  closed  and 
the  old  direct  route 
through  the  bowel  re- 
stored   (Fig.    105). 

During  the  month  of 
this  stay  in  the  surgical 
wards  after  this  opera- 
tion she  had  three  waves 
of  fever,  ranging  in  the 
neighborhood  of  100°  F. 
and  lasting  about  a  week 
each,  with  four  or  five 
days  intervening.  She 
continued  to  vomit,  but 
somewhat  less  severely, 
and  also  gained  in 
strength. 

A  year  later,  August 
27,  1909,  she  reported, 
feeling  well  but  looking 
thin.  She  was  at  that 
time  eating  no  meat  and 
was  given  advice  as  to 
her  diet. 


DYSPEPSIA 


297 


She  was  next  seen  June  10,  1910,  and  stated  at  that  time  that 
she  had  not  been  troubled  with  vomiting  since  her  last  operation, 
but  that  two  or  three  months  ago  she  was  kicked  in  the  abdomen 
by  a  drunken  man  and  since  that  has  gradually  lost  strength,  though 
her  pain  has  been  only  slight.  A  week  ago  she  began  to  have  more 
or  less  persistent  retching  and  slight  epigastric  pain  when  standing. 
She  had  much  nausea  and  tenderness,  and  was  unable  to  stand  on 
account  of  weakness.  There  was  also  edema  of  the  feet  on  stand- 
ing. July  15th  she  was  transferred  to  the  medical  wards,  where  she 
remained  until  September  21st. 


Fig.  107. — Area  of  cutaneous  hyperesthesia  in  Case  117. 

The  most  striking  feature  of  her  case  during  that  period  is  shown 
in  Fig.  106,  which  displays  a  continuous  fever,  lasting  thirteen  weeks. 
It  will  be  noted  that  during  the  first  week  of  her  stay  in  the  medical 
wards  there  was  no  fever  to  speak  of.  Another  remarkable  feature 
of  her  stay  was  a  gain  of  weight  during  this  period  of  prolonged 
pyrexia.  She  weighed  82  pounds  June  2 2d,  when  her  fever  began, 
and  September  i6th,  after  three  months'  fever,  weighed  88|  pounds. 
During  most  of  the  three  months  of  this  third  stay  in  the  Massachu- 
setts General  Hospital  she  complained  of  epigastric  pain  for  which 
nothing  could  be  found  to  account.  An  area  of  superficial  skin 
tenderness  was   constant   and   marked    (Figs.    107   and    108).     The 


298 


DIFFERENTLA.L  DLA.GNOSIS 


leukocytes  were  never  increased.  There  was  at  no  time  any  spasm  or 
deep  tenderness,  but  the  pain  was  severe  enough  to  require  morphin 
at  times. 

There  Was  at  no  time  any  agglutinative  reaction  with  typhoid 
culture  or  with  alpha  or  beta  paratyphoid.  The  Wassermann  reaction 
was  negative.  "Bed  fever"  was  excluded  by  having  the  patient  sit 
up  for  a  number  of  days  without  producing  any  diminution  in  the 
fever.  A  perinephric  abscess,  subacute  peritonitis,  tuberculous 
peritonitis,  subphrenic  abscess  were  among  the  diagnoses  suggested. 
The  urine  was  never  abnormal.     Orthopedic  examination  by  Dr.  R.  B. 


Fig.  108. — Area  of  cutaneous  hjqjeresthesia  in  Case  117. 

Osgood  showed  nothing  of  significance.  The  fundus  of  the  eye  was 
normal.  Blood-culture  and  cultures  from  the  urine  remained  sterile. 
The  color  fields  were  plotted  (Fig.  109)  and  found  normal.  Ten  tests 
of  the  feces  were  negative  to  guaiac.  She  was  repeatedly  :i;-rayed 
without  result. 

Her  pain  was  partly  relieved  in  August  by  the  aid  of  high  oil 
enemata,  but  she  remained  very  nervous  and  thin  and  ate  but  little. 
Agar-agar  increased  the  bulk  of  the  stools,  but  had  no  effect  upon 
the  temperature.  The  skin  reaction  to  tuberculin  was  slightly  posi- 
tive; 15  minims  of  the  sediment  of  a  catheter  specimen  of  urine  was 


DYSPEPSIA 


299 


injected  into  a  guinea-pig  July  220!.  The  animal  was  autopsicd 
September  i,  1910,  and  no  results  found.  On  the  21st  of  September  she 
went  home  quite  unimproved,  quite  unexplained,  and  still  markedly 
febrile. 

October  24,  19 10,  she  returned  to  the  hospital  to  report,  and 
stated  that  she  had  been  up  and  about  the  house  at  home,  gaining 
strength,  and  having  less  pain.  She  has  kept  her  temperature  chart, 
the  range  of  which  is  shown  in  Fig.  no. 

The  area  of  cutaneous  tenderness  was  as  before.  She  stayed  only 
a  few  days  this  time  for  observation  and  went  home  on  the  27th, 
weighing  92  pounds. 


Fig.  109. — Chart  of  color  fields  of  Case  117. 


Discussion. — It  does  not  seem  to  be  worth  while  to  discuss  the 
various  possibilities  of  diagnosis  at  the  time  of  this  patient's  first 
visit  to  the  Massachusetts  General  Hospital.  The  most  mysterious 
and  interesting  part  of  her  illness  begins  when  she  returned  to  the  Mas- 
sachusetts General  Hospital,  after  five  years,  of  what  she  called  vomit- 
ing and  five  operations  for  supposed  adhesions  about  the  stomach.  The 
fact  that  she  was  well  nourished  at  this  time  makes  me  tolerably  sure 
that  her  "vomiting"  never  deserved  that  term,  but  was  wholly  a  matter 
of  regurgitating  a  small  part  of  the  meal  last  eaten,  a  process  familiar 
enough  in  babies,  whose  mothers  often  refer  to  it  as  "spilling  over." 
At  this  time  the  rather  unusual  operation  oj  undoing  gastro-enteros- 


300 


DIFFERENTIAL  DIAGNOSIS 


tomv  and  attempting  to  restore  the  norfnal  course  of  the  bowel  was 
performed.  The  idea  of  this  operation  was  that  the  patient's  troubles 
were  due  more  to  meddlesome  surgery  than  to  any  other  one  factor, 
and  that  the  best  help  we  could  give  her  was  to  restore  her  as  nearly 
as  possible  to  her  natural  condition  before  surgery  was  attempted. 

Apparently,  then,  this  attempt  to  undo  the  bad  effects  of  surgery 
was  a  successful  one,  for  she  had  two  years  of  good  health,  despite  a 
curious  and  quite  unexplained  fever  during  convalescence  from  this 
last  operation. 

We  come  next  to  the  most  inexplicable  chapter  of  this  patient's 
hospital  life,  namely,  her  thirteen  weeks  of  unexplained  fever  asso- 


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Fig.  no. — Second  temperature  chart  of  Case  117. 


ciated  with  gain  in  weight.  I  have  never  been  more  thoroughly 
baffled  in  the  study  of  a  case  than  in  this.  As  the  record  shows,  we 
did  everything  that  anyone  could  suggest  to  find  out  the  cause  of 
her  fever,  but  in  the  end  we  knew  as  little  as  in  the  beginning.  The 
important  point  is  that  after  she  left  the  hospital  and  without  any 
reference  to  treatment  given  by  us  or  anyone  else,  her  fever  went 
down  and  she  got  entirely  well.  To  my  thinking,  the  case  illus- 
trates several  points:  First,  the  harm  of  operating  merely  for  adhe- 
sions. The  more  I  see  of  such  operations,  the  less  I  think  of  them. 
I  have  yet  to  be  convinced  that  adhesions  about  the  stomach,  gall- 
bladder, or  appendix  are  the  cause  of  symptoms  in  any  considerable 


DYSPEPSIA  301 

proportion  of  the  cases  in  which  they  occur.  The  vast  majority  of 
operations  done  for  adhesions  and  carefully  followed  afterward  prove 
to  be  useless  or  worse.  The  second  point  of  interest  is  the  definite 
record  of  what  our  grandfathers  used  to  call  a  "  simple  fever,"  or  per- 
haps a  "gastric  fever,"  wholly  unexplained,  entirely  benign,  and, 
strangest  of  all,  concident  with  gain  in  weight!  They  covered  up 
their  ignorance  with  names.  We  are  as  ignorant,  but  confess  it.  I 
have  no  explanation  to  give  of  the  area  of  cutaneous  tenderness 
which  occasioned  some  of  the  bitterest  of  her  complaints,  and  was 
just  as  marked  after  her  complete  recovery  as  during  the  worst  of  her 
illness.  ' 

Case  118 

A  housewife  of  thirty-five  entered  the  hospital  June  26,  19 10. 
At  the  age  of  seventeen  she  says  she  had  trouble  with  both  lungs  and 
"pined  away  to  nothing,"  as  the  result  of  a  cough  with  which  she 
raised  blood.  For  the  last  four  years  she  has  again  had  a  cough,  but 
has  not  raised  blood.  Four  years  ago  she  used  to  have  what  she  calls 
"nervous  fits,"  but  for  the  past  two  and  a  half  years  has  not  had  any. 
Within  the  last  four  months  she  has  taken  a  little  brandy  for  her 
s)anptoms.  She  states  that  her  menstruation  comes  every  two  weeks. 
She  has  had  no  children,  but  two  miscarriages,  the  last  eight  years 
ago. 

Four  months  ago- her  food  began  to  "He  like  a  lump"  in  her  stom- 
ach, and  she  had  nausea,  but  no  vomiting.  The  epigastric  distress 
was  not  worse  after  meals  and  was  not  relieved  by  cooking  soda. 
Three  weeks  ago  she  vomited  a  teaspoonful  of  blood  after  violent 
retching  before  breakfast.  Morning  nausea  has  been  frequent  since 
that  time.  Meat  is  particularly  distressing  to  her.  She  states  that 
she  has  lost  no  weight,  but  feels  very  weak. 

Physical  examination  showed  an  obese  Scandinavian  woman  with 
pupils  irregular,  but  reacting  normally.  The  heart  was  negative  and 
the  lungs  likewise,  except  for  a  few  squeaks  scattered  in  both  backs 
and  in  the  left  front.  The  abdomen  is  full,  tympanitic,  and  some- 
what tender  throughout,  especially  in  the  epigastrium,  left  flank,  and 
right  iliac  fossa.  In  the  left  front,  near  the  second  and  third  ribs, 
inspiration  is  interrupted  and  high-pitched.  Blood  and  urine  are 
normal.     Systolic  blood-pressure,  145  mm.  Hg. 

The  patient  was  starved  for  thirty-six  hours,  after  which  she 
was  given  a  diet  of  crackers  and  milk  and  speedily  recovered  her 
strength.   By  July  3d  she  was  able  to  take  an  ordinary  diet,  and  by 


302  DIFFERENTIAL   DIAGNOSIS 

the  5th  she  seemed  perfectly  well  and  ready  to  go  home.  Our  suspi- 
cions were  that  she  took  more  than  a  httle  brandy. 

Discussion. — Evidently  this  patient  had  pulmonary  tuberculosis 
in  her  younger  days  and  got  over  it  without  any  special  treatment. 
It  is  worth  noting  that  this  often  happens.  It  may  serve  to  make  us 
somewhat  less  confident  that  the  recoveries  following  sanitarium 
treatment  are  always  due  to  that  treatment. 

We  have  no  way  of  telling  what  her  "nervous  fits"  were.  No 
trained  observer  watched  them,  and  they  did  not  occur  during  the 
period  of  illness  which  we  studied. 

The  dyspepsia  of  the  last  four  months  is  not  characteristic  in  any 
way  of  any  particular  disease.  It  obviously  has  not  interfered  with 
the  ordinary  functions  of  the  stomach,  for  the  patient  is  still  obese. 
That  it  resulted  in  the  vomiting  of  a  teaspoonful  of  blood  after  violent 
retching  is  not  especially  significant  or  helpful  as  to  diagnosis.  It 
seems  clear  to  me  that  this  may  result,  whatever  be  the  cause  of  the 
retching.  I  have  seen  it  occur  on  shipboard  as  the  result  of  sea- 
sickness. 

The  physical  signs  in  the  chest  are  presumably  those  of  a  healed 
phthisical  process.  Otherwise  the  physical  examination  tells  us 
nothing  of  importance.  In  the  end  we  could  not  be  siire  of  the  diag- 
nosis, but  the  prompt  improvement,  dating  from  the  time  when  she 
was  separated  from  her  brandy,  is  certainly  suggestive. 

Case  119 

A  Scotch-Canadian  laborer  of  fifty-eight  entered  the  hospital 
August  28,  1910.  For  about  twenty  years  he  has  had  attacks  of  indi- 
gestion at  intervals  of  a  few  weeks  to  two  or  three  years,  lasting  a  few 
hours  to  several  days.  Between  attacks  he  is  fairly  well,  except  for 
constipation  and  a  Httle  vague  abdominal  distress.  The  present 
attack,  which  he  considers  a  fair  sample  of  others,  began  nine  days 
ago  with  shght  heart-burn.  Next  day  his  stomach  soured  and  he 
vomited  twice,  but  worked  all  day.  This  continued  for  the  following 
day  and  more  or  less  ever  since.  Pain  is  increased  during  the  hour 
following  the  meal,  but  relieved  by  soda  or  by  vomiting.  Six  days  ago 
he  had  severe  cramps  in  different  parts  of  the  abdomen,  and  heard  a 
good  deal  of  gurgling,  accompanying  a  slight  diarrhea,  which  ceased 
the  same  day.  He  has  worked  until  three  weeks  ago,  and  says  that  in 
those  three  weeks  he  has  lost  20  pounds.  According  to  his  statement, 
he  has  passed  urine  but  once  in  the  last  six  days  without  catheteriza- 
tion, though  he  never  had  to  be  catheterized  before. 


DYSPEPSIA  303 

On  examination  he  was  emaciated  and  looked  twenty  years  older 
than  he  was.  His  pupils  and  gums  were  normal,  chest  negative, 
artery  walls  tortuous  and  thickened.  Abdomen  tender  on  deep 
pressure  in  the  left  hypochondrium.  Reflexes  normal.  Blood  and 
urine  normal.  The  feces,  examined  every  day  or  two  for  a  month, 
showed  a  slight  or  moderate  reaction  to  guaiac  in  about  half  the 
examinations.  They  were  not  otherwise  abnormal.  The  stomach 
showed  no  fasting  contents,  and,  after  a  test-meal,  free  HCl  0.03  per 
cent.;  total  acidity,  0.07  per  cent.  No  reaction  to  guaiac.  Rectal 
examination  negative.  Capacity  of  the  stomach  was  1900  c.c,  and 
the  inflated  stomach  reached  from  the  ensiform  to  a  point  3  cm. 
below  the  navel. 

The  patient  was  exceedingly  reticent  and  morose,  but  did  not 
appear  to  suffer  much.  During  the  month  of  his  stay  in  the  hospital 
he  gained  3  pounds  in  weight,  showed  no  fever,  and  complained  chiefly 
of  gas  in  his  stomach.  His  abdomen  was  always  soft.  He  had  one  or 
two  attacks  of  vomiting,  but  nevertheless  improved  very  much. 
Upon  the  whole,  it  was  thought  that  there  was  no  basis  to  warrant 
surgical  interference.  He  was  seen  by  Dr.  C.  A.  Porter,  who  did  not 
desire  to  operate. 

A  year  later,  July  7,  191 1,  he  entered  again,  and  stated  at  that  time 
that  he  got  along  comfortably  until  two  months  ago  and  had  gained 
5  pounds  over  his  weight  at  the  time  of  leaving  the  hospital.  About 
May  I,  191 1,  he  began  to  vomit  approximately  once  a  week,  but  by 
care  in  his  diet  could  usually  avoid  it.  The  vomitus  has  never  been 
bloody,  but  sometimes  brown.  He  has  distress  in  the  epigastrium 
about  fifteen  minutes  after  meals.  This  distress  is  relieved  by  sodium 
bicarbonate,  but  he  regards  this  as  an  unnatural  and  dangerous  drug, 
vicious  as  whisky,  hence  has  used  it  very  little.  At  the  time  of  enter- 
ing the  hospital  he  had  a  spasmodic  stiff  neck  which  troubled  him 
more  than  his  stomach.  Physical  examination  was  essentially  the 
same  as  before;  :r-ray  examination  showed  no  important  abnormality 
in  the  spine.  The  stiff  neck  disappeared  in  the  course  of  ten  days. 
It  was  not  accompanied  by  any  fever.  During  the  last  of  his  three 
weeks'  stay  in  the  hospital  he  complained  of  nothing  and  seemed  to  be 
entirely  well,  though  on  the  day  following  entrance  he  vomited  16 
ounces  of  a  brownish  watery  fluid,  with  a  strong  reaction  to  guaiac. 
Dr.  Porter  saw  him  again  and  did  not  advise  operation.  Guaiac  test 
was  positive  in  the  stools  on  the  day  following  the  vomiting  of  blood, 
not  at  any  other  time. 

Discussion. — This  patient  has  had  twenty  years  of  short  dyspeptic 


304  DIPFERENTIAL  DIAGNOSIS 

attacks  "Associated  with  diarrhea.  At  the  present  time  he  shows  a 
positive  guaiac  test  in  about  half  the  stools  examined.  His  stomach 
is  a  little  large,  but  shows  nothing  of  importance.  We  did  not  settle, 
to  my  satisfaction,  the  cause  of  his  troubles.  Possibly  his  arterio- 
sclerosis may  have  accounted  for  them,  but  my  impression  is  that 
some  mental  or  social  trouble  was  back  of  all  his  symptoms.  There 
was  no  proper  follow-up  work  done  upon  the  case,  so  that  I  cannot  re- 
cord anything  better  than  my  own  impressions;  but  I  have  seen  a 
number  of  similar  cases  in  which  the  study  of  the  patient's  personal 
and  family  life  revealed  an  abundance  of  disturbing  causes,  such  as 
were  quite  sufficient  to  upset  anyone's  stomach.  In  many  hospital 
cases  these  causes  are  entirely  neglected  or  forgotten.  The  old- 
fashioned  family  practitioner,  who  still  pUes  his  beneficent  work 
in  smaller  towns  and  country  districts,  understands  and  treats  this 
sort  of  a  case  far  better  than  the  so-called  scientific  physician,  whose 
chnic  is  so  arranged  that  he  cannot  possibly  know  anything  about  the 
mental  life  or  personal  problems  of  his  patient. 

Case  120 

An  Italian  laborer  of  fifty-six  entered  the  hospital  August  28,  19 10, 
complaining  of  a  month's  abdominal  pain,  nausea,  and  vomiting. 
For  two  years  he  has  had  also  a  persistent  cough,  and  a  year  ago  a 
slight  hemoptysis,  lasting  intermittently  for  a  week  and  recurring 
three  or  four  times  since.  Never  been  sick  in  bed.  He  denies  venereal 
disease,  but  has  drank  heavily  until  two  years  ago,  since  when  he  has 
been  moderate.     The  family  history  is  good. 

At  the  present  time  the  cough  has  subsided  and  the  gastric  symp- 
toms are  his  main  trouble.  His  bowels  have  moved  two  or  three  times 
daily  and  the  movements  have  sometimes  contained  blood.  His 
appetite  has  been  good,  but  food  causes  gastric  pain.  Last  night  he 
vomited  three  or  four  times  and  was  afterward  unable  to  retain  any 
food.     The  vomitus  was  said  to  be  black. 

On  examination  patient  was  somnolent  and  slightly  pale.  Pupils 
negative.  No  lead  line.  Heart's  apex  in  the  fifth  interspace  nipple 
fine,  right  border  2.5  cm.  from  midsternum,  no  murmurs.  Pulmonic 
second  greater  than  the  aortic  second. 

Lungs  showed  throughout  increased  resonance,  diminished  breath 
sounds,  prolonged  expiration,  and  many  squeaks  and  crackles.  Show- 
ers of  fine  crackles  were  especially  numerous  at  the  right  base.  The 
abdomen  showed  considerable  tenderness  in  the  right  upper  quadrant 
with  involuntary  spasm.      The  fiver  dulness  was  normal,   reflexes 


DYSPEPSIA  305 

normal.  The  rectum  was  ballooned  and  empty,  and  a  little  pure  pus 
was  expelled  soon  after  entrance.  Next  morning  his  chief  complaint 
was  of  severe  pain  across  the  upper  abdomen  and  lower  chest.  The 
urine  was  17  ounces  in  the  first  twenty-four  hours,  the  small  amount 
being  accounted  for  by  profuse  catharsis.  Specific  gravity,  1012, 
with  a  trace  of  albumin  and  no  recognizable  sediment.  White  cells 
numbered  22,500,  with  89  per  cent,  of  polynuclears.  Hemoglobin, 
75  per  cent.  A  specimen  of  urine  planted  on  blood-serum  showed  no 
growth.  His  purulent  sputum  planted  on  blood  agar  showed  no 
growth  of  influenza  bacilli,  though  film  specimens  of  the  same  sputum 
showed  influenza  bacilli.  No  tubercle  bacilli.  Examination  of  the 
feces  August  29th  and  30th  showed  large  amount  of  pus,  but  little  food 
residue  and  strong  reaction  to  guaiac.     No  blood-pressure  recorded. 

The  patient  could  retain  nothing  by  mouth  or  by  rectum.  He 
was  given  subpectoral  injections  of  glucose  solution,  but  they  were 
not  well  absorbed.  On  account  of  the  abdominal  spasm  and  the  pur- 
ulent rectal  discharge  it  was  thought  that  the  patient  had  a  local  peri- 
tonitis which  had  broken  into  the  intestine  and  was  draining  by  rectum. 
As  a  source  for  this  peritonitis,  perforated  duodenal  ulcer  and  empy- 
ema of  the  gall-bladder  were  considered.  The  ohguria  soon  im- 
proved, and  it  was  thought  to  be  due  either  to  some  serious  kidney 
lesion  or  simply  to  the  fact  that  he  was  absorbing  no  fluid  to  speak 
of  either  by  the  stomach  or  otherwise.  The  similarity  between  the 
sputum  and  the  pus  passed  by  rectum,  both  in  its  appearance  and  bac- 
teriologic  contents,  was  remarked  upon.  He  was  seen  twice  by  Dr.  C. 
A.  Porter  in  order  to  determine  the  question  of  surgical  interference, 
but  no  such  interference  was  advised. 

Discussion. — Very  possibly  this  patient  had  phthisis  at  the  time 
of  his  persistent  cough  two  years  ago,  but,  so  far  as  we  can  see,  the  net 
effect  of  this  illness  was  good,  for  it  seems  to  have  resulted  in  his  giving 
up  alcohol  or,  at  any  rate,  moderating  his  reaction  to  that  stimulant. 

At  the  present  time  he  has  a  dyspepsia  without  any  special  diag- 
nostic ear-marks  or  peculiarities.  From  the  history  alone  no  one 
could  guess  its  cause.. 

From  the  physical  examination  one  would  suppose  that  he  had 
had  a  bronchiectasis,  an  ulcerative  colitis,  and  some  type  of  nephritis. 
When  the  predominating  organism  in  the  sputum  is  the  influenza 
bacillus,  when  the  patient's  lung  signs  are  distributed  throughout  both 
lungs  and  are  presumably  of  long  duration,  bronchiectasis  is  usuaUy 
the  correct  diagnosis.  His  dyspepsia  is  presumably  a  resultant  of  the 
different  infections  above  enumerated. 

Vol.  11—20 


3o6 


DIFFERENTIAL  DIAGNOSIS 


Outcome. —  The  patient  died  August  31st,  the  diagnosis  being 
chronic  bronchitis,  emphysema,  bronchiectasis,  and  some  suppurative 
process  in  the  abdomen,  perforating  the  colon. 

Autopsy  showed  amyloid  nephritis,  hypertrophy  and  dilatation 
of  the  heart,  localized  bronchitis,  and  purulent  bronchitis  of  the  left 
lung;  bronchopneumonia  of  the  right  lung;  chronic  plcuritis,  ulcers 
of  the  gall-bladder,  ulcerative  enteritis,  and  coHtis. 

Case  121 

A  shoemaker  of  sixty-four  entered  the  hospital  September  10,  1910, 
complaining  that  for  the  past  year  he  has  gradually  lost  his  appetite 


Fig.  III. — Lung  signs  in  Case  121. 

and  strength.  He  has  been  more  constipated  than  usual  and  has  had 
severe  headaches.  For  about  two  months  he  has  had  constant  soreness 
in  the  epigastrium  and  a  sensation  "like  a  bullet  trying  to  come  up." 
The  latter  usually  comes  on  about  9  P.  M.  and  lasts  several  hours. 
Somewhat  relieved  by  hot  drinks.  During  the  last  ten  days  he  has 
begun  to  vomit,  the  vomitus  being  always  small  in  amount,  but  once 
containing  skins  of  peaches  eaten  twenty-four  hours  previously. 
It  has  never  contained  blood  or  coffee-grounds.  Usual  weight  up  to 
last  winter,  145  pounds;  his  present  weight,  125  pounds.     He  retired 


DYSPEPSIA 


307 


from  work  two  years  ago  to  take  care  of  an  invalid  wife.    He  entered 
the  hospital  with  a  diagnosis  of  gastric  cancer. 

On  physical  examination  he  was  fairly  nourished,  normal  pupils 
and  gums,  heart  negative,  abdomen  negative,  knee-jerks  and  other 
reflexes  negative,  lungs  as  per  Figs,  in,  112.  His  sputum  negative  for 
tuberculosis.  No  single  type  of  organism  predominates.  The  stools 
September  13th  and  15th  gave  a  reaction  to  guaiac.  The  stomach- 
tube  was  introduced  and  showed  no  fasting  contents.  Test-meal 
was  gone  at  the  end  of  an  hour.  In  the  wash-water  no  free  hydro- 
chloric acid  was  detected.     Capacity  of  the  organ  was  870  c.c. 


Fig.  112. — Lung  signs  in  Case  121. 

During  a  week's  stay  in  the  hospital  he  had  no  fever  and  his  blood 
and  urine  were  normal.  He  seldom  coughed,  and  had  no  gastric 
S5nnptoms  after  the  first  few  days  of  thorough  rest. 

Discussion. — But  for  the  negative  results  of  gastric  examination, 
this  case  might  well  be  one  of  gastric  cancer.  As  it  is,  I  see  no  good 
reason  to  doubt  that  it  is  similar  to  many  others  which  I  have  studied 
within  the  past  ten  years  in  which  the  entire  foreground  of  the  clinical 
picture  is  occupied  with  gastric  complaints,  while  phthisis  is  their  real 
cause.  It  is  to  be  noted  that  this  patient  said  nothing  about  cough 
or  any  other  pulmonary  symptom,  yet  the  signs  in  his  lungs  were  very 
marked.  Although  bacilh  were  not  found,  there  is  no  considerable 
doubt  that  he  had  had  tuberculosis. 


3o8  DIFFERENTIAL  DIAGNOSIS 

Outcome. — It  was  subsequently  learned  that  twenty-six  years 
ago  he  had  a  fistula  in  ano,  lasting  about  a  year  and  cured  by  opera- 
tion. At  this  time  he  was  having  a  slight  cough,  and  one  day,  during 
a  fit  of  laughter,  blood  gushed  in  great  mouthfuls  from  his  throat 
and  nostrils.  He  was  very  weak  after  this  and  spent  a  year  in 
recuperating,  but  after  that  time  seemed  to  be  well.  For  the  last 
fifteen  winters  he  had  coughed  a  good  deal,  but  had  never  given  up 
work. 

The  patient  died  a  few  months  after  leaving  the  hospital. 

Case  122 

A  house  painter  of  fifty-seven  entered  the  hospital  September  28, 
1910,  with  a  diagnosis  of  "family  jaundice"  or  gall-stones.  His 
mother  died  at  sixty-three  of  dropsy.  She  suffered  from  jaundice 
for  twenty  years  before  her  death  and  had  attacks  of  pain  and  vomit- 
ing at  various  times.  One  of  her  children  was  slightly  jaundiced, 
off  and  on,  for  years,  but  died  at  fifty-nine.  Another,  still  living  at 
sixty-eight,  has  had  attacks  of  abdominal  pain  with  vomiting  and 
jaundice  in  periods  covering  thirty  years.  Five  other  children  have 
never  been  jaundiced.  The  patient's  maternal  aunt  had  similar 
attacks  of  pain,  vomiting,  and  jaundice  for  a  number  of  years. 

The  patient's  own  past  history  is  negative.  He  takes  three 
sherries  a  day  and  an  occasional  drink  of  rum.  Sometimes  he  has 
whisky  before  breakfast.     Otherwise  his  habits  are  good. 

For  twenty  years  he  has  had  attacks  of  jaundice  once  or  twice 
a  year,  lasting  from  one  to  three  weeks.  Of  late  these  attacks  have 
been  somewhat  more  frequent.  At  the  onset  of  such  attacks  he  feels 
unusual  sleepiness  and  is  sometimes  feverish.  Shortly  after  this  he 
begins  to  vomit,  usually  from  one-half  to  one  hour  after  meals.  Vom- 
itus  has  never  been  large  in  amount,  but  has  sometimes  contained  food 
eaten  the  day  before. '  Twenty  years  ago  he  vomited  about  a  pint  of 
blood,  and  twelve  years  ago  saw  streaks  of  blood  in  the  vomitus. 
He  has  sometimes  noticed  that  his  stools  are  "black  as  ink,"  even  when 
taking  no  medicine.  At  other  times  they  are  clay  colored.  He  com- 
plains of  three  varieties  of  pain:  First,  heartburn,  coming  on  an  hour 
or  two  after  meals,  for  the  relief  of  which  he  has  consumed  large 
quantities  of  soda;  second,  coHc  in  the  middle  and  upper  abdomen, 
reheved  by  passing  gas  downward;  third,  a  vague  discomfort  in  the 
right  flank,  which  makes  him  unable  to  lie  upon  his  right  side,  but 
bears  no  relation  to  meals. 

For  ten  years  he  has  had  to  urinate  about  twelve  times  each 


DYSPEPSIA  309 

night,  the  aggregate  result  being  about  a  quart.  Twenty  years  ago  he 
weighed  160  pounds,  a  year  ago  131  pounds,  now  121  pounds.  He 
has  followed  his  present  occupation  as  a  house  painter  for  eighteen 
years,  but  says  that  he  had  these  attacks  "before  he  ever  saw  a  paint- 
brush." 

Physical  examination  showed  poor  nutrition  and  marked  weak- 
ness. The  abdomen  was  strikingly  freckled  with  brown  spots,  2  to  3 
mm.  in  diameter.  Mucous  membranes  were  pale  and  slightly  cyan- 
osed.  The  sclerae  showed  a  slight  lemon  tint  in  the  deeper  parts, 
but  around  the  iris  were  white.  There  was  no  lead  line,  but  his  teeth 
were  all  gone  on  the  upper  jaw  and  few  were  left  upon  the  lower. 
The  heart  and  lungs  showed  nothing  abnormal.  Blood-pressure, 
150  systohc,  80  diastolic;  urine,  70  to  90  ounces  in  twenty-four  hours; 
specific  gravity,  ion  to  1017,  sediment  not  remarkable.  Examina- 
tion of  the  blood  showed  red  cells  3,000,000;  white  cells,  4000  to  8000; 
hemoglobin,  55  per  cent.  The  stained  specimen  showed  no  achromia 
and  a  tendency  to  an  increased  size  in  the  red  cells;  some  variations 
in  size  and  shape,  no  nucleated  forms,  no  stippling.  The  general 
appearance  of  the  blood  distinctly  suggested  pernicious  anemia. 

The  abdomen  was  tympanitic  throughout,  and  showed  a  slight 
general  tenderness  on  deep  palpation,  most  marked  on  the  right 
flank.  The  liver  dulness  extended  from  the  sixth  rib  to  a  point  5  cm. 
below  the  costal  margin.  Its  surface  and  edge  were  apparently 
smooth.     Spleen  not  felt.     Reflexes  normal. 

Discussion. — Our  attention  is  at  once  attracted  by  a  number  of 
different  diagnostic  possibiHties : 

(i)  In  the  first  place  he  is  a  painter,  and  almost  any  sort  of  indi- 
gestion might  be  the  result  of  lead-poisoning. 

(2)  In  the  second  place  he  is  an  alcoholic,  and  the  same  might  be 
said  as  to  the  effects  of  alcohol. 

(3)  In  the  third  place  he  gives  a  history  of  vomiting  a  large 
amount  of  blood  and  having  black  stools.  The  commonest  cause  of 
these  occurrences  (if  they  really  did  occur)  is  hepatic  cirrhosis. 

(4)  He,  as  well  as  his  mother  and  two  other  members  of  the 
family,  seem  to  have  suffered  from  jaundice.  According  to  his  own 
account  he  must  have  had  forty  attacks,  which  seems  highly  im- 
probable. 

(5)  His  nocturia  may  mean  failing  heart  or  prostatic  obstruction. 

(6)  Besides  all  these  definite  possibilities,  he  launches  us  upon  a 
wholly  uncharted  sea,  as  he  tells  the  story  of  his  three  varieties  of 
pain.     None  of  these  pains  gives  us  anything  characteristic  or  definite 


3IO  DIFFERENTIAL  DIAGNOSIS 

to  take  hold  of.  We  must  look  to  the  physical  examination  to  orient 
us. 

One  of  the  first  facts  to  be  noted  in  the  physical  examination 
tends  to  mystify  us  still  further.  Why  should  he  have  freckles  on  his 
abdomen?  I  know  no  way  to  answer  the  question.  As  we  go  on 
through  the  physical  examination,  we  note  that  he  has  a  type  of 
urine  often  associated  with  a  contracted  kidney,  whether  of  the  arterio- 
sclerotic or  glomerular  type  of  nephritis.  We  note,  moreover,  that 
he  has  a  severe  anemia,  which  might  perfectly  well  be  of  the  pernicious 
type,  as  the  history  suggests.  In  the  internal  viscera  the  enlarged 
liver  is  the  most  striking  abnormality. 

Putting  this  all  together,  it  seems  to  me  that  the  two  most  probable 
diagnoses  are  cirrhosis  or  syphilis.  Either  of  these  might  cause  all 
his  symptoms.  For  the  one  we  have  an  efilicient  treatment,  for  the 
other  no  treatment  at  all.  The  reasonable  course,  therefore,  is  to 
treat  him  for  syphilis. 

Outcome. — It  was  subsequently  learned  that  three  years  ago  he 
spent  eighteen  months  at  an  almshouse  hospital,  with  marked  edema 
of  the  legs  and  ascites.  At  that  time  he  was  tapped  three  times,  and 
on  the  first  occasion  4  gallons  of  slightly  bloody  fluid  were  evacuated. 
For  the  last  eighteen  months  there  has  been  no  edema  and  no  ascites. 
He  worked  until  ten  days  ago.  After  ten  days'  stay  in  the  hospital, 
with  laxatives  and  an  occasional  hypnotic,  he  presented  no  symptoms, 
seemed  very  cheerful,  and  was  discharged. 

Case  123 

A  factory  girl  of  nineteen  entered  the  hospital  September  28,  19 10, 
complaining  of  stomach  trouble,  constant  and  increasing  in  severity 
for  the  last  year,  especially  for  three  months.  She  has  continual  dull, 
non-radiating  pain  in  the  epigastrium,  less  severe  in  the  first  hour  after 
meals,  then  sharper  for  the  next  hour.  It  bears  no  relation  to  the  kind 
of  food.  In  the  last  two  months  she  has  vomited  about  an  hour  after 
almost  every  meal.  Vomitus  never  contains  blood,  has  been  small  in 
quantity,  occasionally  showing  traces  of  the  food  eaten  the  day  before. 
During  the  past  two  months  her  appetite  has  failed  and  she  has  lost 
weight.  Usual  standard  weight  being  158  pounds,  she  now  weighs 
145  pounds.  She  has  worked  about  half-time  until  four  days  ago. 
There  are  no  disturbing  mental  factors  as  far  as  she  knows.  Bowels 
move  daily.  She  has  no  cough.  Family  history,  past  history,  and 
habits  are  good. 

On  physical  examination   she  is  well  nourished,  skin  and  mucous 


DYSPEPSIA  3 1 1 

membranes  very  pale.  The  heart's  apex  is  13  cm.  from  midsternum 
and  2  cm.  outside  the  midclavicular  line.  The  right  border  2  cm. 
from  midsternum.  There  is  a  soft  systolic  murmur  heard  all  over 
the  precordia  and  in  the  axilla,  but  loudest  at  the  apex.  The  pulmonic 
second  sound  is  accentuated.  The  pulses  are  not  remarkable.  Sys- 
tolic blood-pressure,  105.  Urine  averages  30  ounces  in  twenty-four 
hours;  specific  gravity,  1009,  no  albumin,  no  sugar.  There  is  moder- 
ate tenderness  in  the  epigastrium,  but  visceral  examination  is  other- 
wise negative.  Blood  examination,  September  28th,  shows  the  follow- 
ing: red  cells,  2,500,000;  white,  3000;  hemoglobin,  30  per  cent.  The 
stained  smear  shows  marked  achromia,  moderate  variations  in  size, 
shape,  and  staining  reaction  of  the  red  cells,  no  nucleated  forms. 
The  feces  were  negative  to  guaiac  on  four  occasions. 

Discussion. — The  dyspepsia  of  anemic  factory  girls  is  a  very 
familiar  phenomenon  and  dependent,  I  believe,  upon  many  causes. 
In  the  present  case  the  anemia  is  so  marked  that  all  other  causes 
must  be  relegated  to  a  secondary  or  tertiary  position,  but  when  the 
anemia  of  such  a  working  girl  is  of  lesser  grade  we  often  find  a  multi- 
tude of  hygienic  errors  and  mental  worries  which  have  to  be  corrected 
before  we  can  help  the  patient. 

Some  years  ago  one  would  have  felt  pretty  certain  of  the  existence 
of  gastric  ulcer  in  a  case  of  this  sort.  To-day  we  know  that  such 
lesions  are  far  less  common  in  young  girls  than  they  are  in  middle-aged 
men,  and  that  most  of  the  symptoms  formerly  attributed  to  ulcer  in 
young  girls  are  due  to  errors  in  hygiene,  to  industrial  overpressure, 
to  incipient  tuberculosis,  to  thyrotoxicosis,  or  lead-poisoning. 

It  is,  of  course,  possible  that  this  patient  may  have  lost  blood 
from  a  peptic  ulcer  of  the  duodenum,  and  that  her  anemia  may  be 
secondary  to  this,  and  there  is  nothing  in  the  case  which  enables  us 
absolutely  to  exclude  such  a  diagnosis,  but  the  history  is  certainly 
not  at  all  typical  of  ulcer,  and  much  more  nearly  resembles  that  of 
chlorosis,  a  disease  which  used  to  be  common  and  is  now  rapidly 
becoming  a  rarity  in  all  parts  of  this  country.  No  doubt  her  working 
conditions  have  contributed  something  to  her  troubles  or  have  aggra- 
vated her  chlorosis,  but  it  is  not  at  all  probable  that  they  are  a  sufi&- 
cient  cause  of  her  anemia.     Chlorosis  is  the  most  probable  explanation. 

Outcome. — By  October  19th  the  red  cells  had  risen  to  3,500,000, 
the  hemoglobin  to  55  per  cent.,  and  there  was  less  abnormaUty  in  the 
individuality  of  the  red  cells.  She  was  able  to  eat  everything  with- 
out discomfort.  The  treatment  during  this  period  consisted  of 
gastric  ulcer  diet  and  Blaud's  pills,  20  gr.  three  times  a  day,  and  an 


312 


DIFFERENTIAL  DIAGNOSIS 


occasional  dose  of  sodium  phosphate.  On  further  questioning,  it 
was  found  that  she  had  for  a  long  time  been  taking  a  scanty  and 
hurried  breakfast,  or  none  at  all,  and  a  cold  lunch,  bought  at  a  lunch 
counter  and  eaten  at  the  factory,  where  she  had  been  working  ten 
hours  a  day.  Dr.  E.  A.  Codman  considered  the  case  one  of  ulcer  of 
the  lesser  curvature,  but  advised  against  operation.  Patient  gained 
4  pounds  during  her  stay  in  the  hospital.  In  November,  191 2,  she 
reported  that  she  was  at  work  and  feeling  perfectly  well.  Further 
details  were  obtained  at  this  time  regarding  the  conditions  of  her 
work.  She  has  been  in  industrial  life  since  thirteen,  and  for  the  past 
five  years  has  been  fusing  wires  into  the  glass  stems  of  incandescent 
electric-light  bulbs.  The  fusing  is  done  with  a  gas  flame.  She  has 
been  doing  piece-work,  and  in  a  ten -hour  day  fixed  3000  of  these  wires 
in  their  glass  stems.  No  windows  could  be  opened  in  the  room  where 
she  worked,  and  the  temperature  was  very  high.  A  month  ago  she 
changed  to  a  paper  and  pasting  job,  and  now  has  good  air  where  she 
works  and  only  an  eight-hour  day.  At  the  present  time  her  hemo- 
globin is  85  per  cent,  and  her  weight  145  pounds. 

Case  124 

A  housewife  of  forty  entered  the  hospital  October  27,  1910.  The 
patient's  complaint  was  that  for  six  months  she  had  had  slight  epi- 
gastric distress  and  regurgitation  of  sour  material  soon  after  eating, 
especially  after  eating  cabbage  or  acid  fruits.  Her  father  died 
at  seventy- two  of  "pleurisy,"  and  her  mother  at  sixty  of  ''bronchial 
trouble."  The  patient  had  rheumatic  fever  at  fifteen,  and  was  three 
months  in  a  hospital.  In  1908  a  painless  lump,  the  size  of  a  pigeon's 
egg,  was  removed  from  her  right  forefinger,  near  the  tip.  It  had  been 
growing  there  four  years.  The  patient  has  one  healthy  child,  ten  years 
old,  and  has  had  one  miscarriage. 

Five  days  ago,  just  after  taking  a  little  toast  and  tea,  she  expe- 
rienced an  entirely  new  sensation — a  queer  feehng  of  fulness  at  the 
epigastrium,  followed  in  a  minute  or  two  by  dizziness  and  blackness 
before  her  eyes.  She  was  chilly  and  perspired  profusely.  She  had 
to  lie  down  and  wanted  the  windows  open,  but  remained  conscious. 
Within  a  few  hours  she  seemed  to  be  nearly  as  well  as  usual,  and  in  the 
next  two  days  washed  and  ironed  and  felt  as  well  as  usual.  Two 
nights  ago  she  felt  a  little  faint,  but  this  soon  passed  off.  Yesterday 
morning,  while  ironing,  she  fainted  away,  and  soon  after  recovering 
consciousness  vomited  over  a  quart  of  bright  red  blood.  Since  then 
she  has  been  in  bed,  starved,  but  comfortable. 


DYSPEPSIA 


313 


Her  physical  examination  was  negative  except  as  concerns  the 
blood  and  the  feces.  The  course  of  her  blood  changes  is  seen  in  Fig. 
113.  A  strong  guaiac  reaction  was  present  in  the  feces  continuously 
from  the  time  of  entrance  until  November  i6th;  after  this  it  was  shght 
or  absent  for  a  few  days,  and  on  November  26th  disappeared  alto- 
gether. At  entrance  she  vomited  26  ounces  of  bright  blood.  The 
pulse  was  almost  impalpable  at  the  wrist,  but  was  counted  later  at 
150.  She  was  given  j  gr.  of  morphin  subcutaneously,  a  hot-water  bag 
at  the  abdomen,  while  the  foot  of  the  bed  was  raised.  Under  this 
treatment  the  pulse  rapidly  improved,  but  she  was  given  nothing  by 


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mouth  until  the  31st,  when  2 -ounce  feedings  of  milk  were  given  every 
two  hours. 

During  the  first  twenty-four  hours  of  her  stay  in  the  hospital  she 
received  i|  gr.  of  morphin,  and  her  respirations  were  kept  at  from 
12  to  15  per  minute.  Normal  sahne  solution  was  given  by  rectum, 
6  ounces  every  six  hours,  and  was  well  retained.  An  ounce  of  brandy 
was  added  to  each  enema.  The  bleedings  did  not  recur.  The  amoimt 
of  milk  was  gradually  raised  to  5  ounces  every  two  hours,  and  Novem- 
ber 3d  crackers  were  added;  November  4th,  lactose;  November  13th, 
eggs,  toast,  and  potato.  She  had  no  symptoms  and  gained  steadily, 
and  by  December  8th  she  felt  well  and  was  allowed  to  go  home. 

Discussion. — The  most  outstanding  fact  about  this  patient  at 
the  present  time  is  her  anemia  (Fig.  113).  This  is  presumably  due 
to  loss  of  blood  vomited  the  day  before  entrance.     It  is  notable 


314 


DIFFERENTIAL  DIAGNOSIS 


in  the  blood  chart  that  her  aneniia  did  not  reach  its  maximum  until 
four  days  later.  This  is  just  what  one  should  expect.  The  blood 
mass  is  diminished  from  the  start,  but  the  sample  drawn  for  examina- 
tion is  unchanged.  Later,  fluid  is  absorbed  into  the  blood-vessels 
from  the  surrounding  tissues.  The  blood  mass  is  restored  and  the 
blood-corpuscles  diluted  at  the  same  time.  This  ordinarily  takes 
from  one  to  three  days,  sometimes  longer. 

What  is  the  source  of  this  patient's  hemorrhage?  Cirrhotic 
liver  and  peptic  ulcer  are  the  most  probable  causes.  There  is  nothing 
in  her  history  to  substantiate  the  idea  of  cirrhosis,  but  such  negative 
evidence  is  by  no  means  sufficient  to  exclude  it.     The  patient  is 

about  the  right  age  for  peptic 
ulcer,  though  her  previous  his- 
tory is  not  at  all  typical  of  that 
affection.  Possibly  much  light 
might  be  thrown  upon  her  case 
could  we  know  the  nature  of 
the  painless  lump  which  was 
removed  from  her  finger  two 
years  previously,  but  it  does 
not  seem  at  all  likely  that  this 
was  either  a  gumma,  a  tubercu- 
lous lesion,  or  a  neoplasm. 

The  slight  fever  which  was 
present  in  the  first  two  weeks 
of  this  patient's  illness  is  char- 
acteristic of  earlier  stages  of 
posthemorrhagic  anemia  and 
does  not  indicate  any  infec- 
tion. This  point  is  not  always 
sufficiently  realized  when  we  are  busy  with  the  differential  diagnosis 
of  a  fever  following  hemorrhage.  On  the  whole,  peptic  ulcer  seems  the 
most  reasonable  diagnosis. 

Outcome. — On  the  8th  of  March,  191 1,  she  wrote  that  she  was 
feehng  remarkably  well  and  had  gained  in  weight.  The  course  of  her 
temperature  during  the  first  three  weeks  in  the  hospital  is  seen  in 
Fig.  114. 


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Fig.  114. — Temperature  chart  of  Case  124. 


Case  125 

A  dressmaker  of  thirty-six  entered  the  hospital  October  30,  1910. 
She  has  been  recommended,  October  7th,  from  the  Out-patient  De- 


DYSPEPSIA  315 

partment  by  Drs.  Badger  and  Lincoln  Davis,  for  subacute  appendi- 
citis, and  was  in  the  West  Surgical  wards  from  October  2 2d  to  30th. 
During  that  time  the  patient  was  afebrile  and  had  negative  urine,  but 
complained  of  vomiting,  pain,  and  tenderness  in  the  epigastrium  and 
right  hypochondrium,  with  a  leukocytosis  of  25,000  and  90  per  cent, 
of  polynuclear  cells.  The  fasting  contents  of  the  stomach  showed 
food,  hydrochloric  acid,  and  a  negative  guaiac  test.  Vaginal  ex- 
amination was  negative. 

The  more  careful  history  taken  in  the  medical  wards  showed  no 
hereditary  taints.  Her  husband  died  two  years  ago  of  a  paralytic 
shock,  at  forty-six.  He  had  been  hemiplegic  for  four  years.  His 
mother,  sister,  and  brother  have  had  similar  paralyses  in  middle  life. 
She  believes  that  her  husband  never  had  venereal  disease.  She 
herself  had  chorea  for  two  years,  from  her  sixth  to  her  eighth  year. 
Her  habits  have  been  good.  She  has  had  no  children  and  no  mis- 
carriage. 

For  three  months  she  has  had  attacks  of  the  above  distress,  first 
three  at  intervals  of  a  week,  after  that  almost  daily  until  her  entrance 
to  the  hospital.  Between  attacks  she  has  some  vague  epigastric  dis- 
comfort. A  typical  attack  begins  with  a  sense  of  bloating,  extending 
from  the  level  of  the  breasts  to  the  pubes.  This  bloating  she  asserts, 
very  confidently,  is  such  that  at  times  she  bursts  her  corsets.  After 
a  period  varying  from  a  few  moments  to  an  hour  a  lump  the  size  of  a 
fist  seems  to  form  in  the  epigastrium  and  right  hypochondrium.  It 
becomes  hard,  relaxes,  and  contracts  again,  rhythmically,  with  about 
two  contractions  per  minute.  By  this  time  the  bloating  subsides,  but 
without  escape  of  gas.  She  may  then  vomit  several  times  with  con- 
siderable relief,  and  the  rhythmic  contractions  are  replaced  by  a  dis- 
tressing sense  of  emptiness  in,  the  lower  abdomen.  The  whole  attack 
lasts  an  hour  or  more,  and  is  not  relieved  by  food  or  drink.  There  is 
very  little  pain  connected  with  it,  and  none  that  radiates  to  the  back, 
scapula,  or  groin.  The  attacks  prevent  sleep,  but  not  work.  They 
may  come  at  any  hour  of  the  day  or  night  without  relation  to  meals, 
rest,  or  exercise.  The  vomitus  is  never  large  in  amount  and  never 
contains  food  eaten  the  day  before.  It  occasionally  shows  a  fine 
dark-brown  sediment  not  accounted  for  by  food  eaten.  There  has 
been  no  jaundice,  no  colic,  no  change  in  the  color  of  the  urine  or 
feces.  Appetite  and  sleep  are  fair.  She  has  worked  steadily.  Her 
best  weight,  seven  years  ago,  was  142  pounds;  now,  136  pounds. 

Physical  examination  showed  good  nutrition,  pupils  equal,  circular, 
and  reacting  normally  to  light  and  distance.     No  glandular  enlarge- 


3l6  DIFFERENTIAL   DIAGNOSIS 

ment.  Chest  negative,  save  for  a  very  soft  systolic  murmur  heard 
over  the  whole  precordia,  loudest  at  the  apex.  Abdomen  was  also 
negative.  Knee-jerks  not  obtained.  Examination  in  a  hot  bath 
showed  nothing  abnormal  in  the  abdomen. 

Discussion. — The  account  given  of  this  patient's  husband  leads  us 
to  surmise  that  he  may  have  had  syphilis,  especially  as  the  patient  has 
had  no  children. 

The  account  of  the  epigastric  pain  sounds  like  that  often  present 
in  appendicitis.  It  also  reminds  us  of  pyloric  spasm,  the  gastric  move- 
ments representing  gastric  peristalsis.  The  gastric  symptoms,  how- 
ever, do  not  read  true  to  any  single  type  of  recognized  gastric  disease, 
and  this  fact  makes  us  all  the  more  keen  to  look  elsewhere  in  the  body 
for  a  source  of  the  stomach  symptoms.  We  naturally  alight  on  the 
absence  of  knee-jerks  as  a  most  significant  fact  in  this  connection. 
It  is  true  that  the  pupils  give  no  support  to  the  hint  aroused  in  our 
minds  by  the  absence  of  knee-jerks.  The  pupils  are  not  those  of 
tabes.  But  if  the  disease  is  confined  to  the  lower  segments  of  the 
cord  we  do  not  expect  involvement  of  the  pupils.  Further  evidence 
of  tabes  should  certainly  be  sought,  and  until  this  is  ruled  out  no 
other  diagnosis  should  receive  equal  consideration. 

Outcome. — It  was  subsequently  learned  that  for  the  past  four  or 
five  months  she  had  felt  darting  pains,  as  if  a  needle  were  thrust  into 
the  fleshy  part  of  both  calves  and  passed  rapidly  through  at  right 
angles  to  the  limb.  Occasionally  she  has  had  similar  sensations  in  the 
heels  or  on  the  dorsum  of  the  foot.  There  has  been  no  disturbance  of 
sphincteric  control,  no  ataxia  or  abnormal  sensations.  A  spinal 
puncture  was  done  November  ist  and  5  c.c.  of  colorless  fluid  obtained, 
the  cell-count  in  which  was  3  per  cubic  millimeter.  Differential 
count  showed  small  lymphocytes,  80  per  cent.;  large  lymphocytes,  4 
per  cent.;  endothelial  cells,  13  per  cent.;  polynuclears,  3  per  cent. 
The  patient  had  a  typical  attack  on  November  6th,  although  the 
bowels  by  this  time  had  started  and  were  moving  well.  The  attack 
was  apparently  aborted  by  giving  5  minims  of  a  mixture  containing 
equal  parts  of  tincture  of  capsicum,  tincture  of  belladonna,  tincture  of 
aconite,  and  tincture  of  actea  racemosa. 

Case  126 

A  housewife  of  fifty-one  entered  the  hospital  November  17,  1910, 
complaining  of  epigastric  distress  which  has  troubled  her  for  three 
years.  It  seems  to  have  no  relation  to  meals,  but  is  worse  at  night. 
She  has  considerable  nausea  and  vomits  very  easily.     In  November, 


DYSPEPSIA  317 

1909,  she  consulted  Dr.  Chase,  of  Plymouth,  on  account  of  vomiting 
of  yellowish-green  bitter  fluid.  Later  she  came  to  the  Out-patient 
Department  and  was  benefited  by  treatment,  but  still  occasionally 
vomited.  Her  bowels  are  costive,  and  at  times  she  has  seen  blood  in 
the  movements.  Nocturia,  two  to  three  times,  for  several  years. 
Slight  hacking  cough  for  a  few  months.  She  has  no  severe  or  parox- 
ysmal pain.  Her  best  weight,  163  pounds,  with  clothes,  was  three 
years  ago.  She  thinks  she  has  lost  20  pounds  in  the  last  four  months. 
Her  weight,  without  clothes,  November  i8th,  was  found  to  be  129 
pounds.  She  has  had  considerable  vertigo  and  some  mental  confusion 
at  times. 

Yet  the  patient  was  well  nourished  and  rosy.  Chest  negative. 
Abdomen  slightly  tender  on  deep  pressure  on  the  right  half.  Reflexes 
normal.  Blood  and  urine  negative.  Systolic  blood-pressure,  160. 
Examined  in  a  hot  bath,  nothing  could  be  made  out  except  consider- 
able tenderness  under  the  right  costal  margin.  She  was  seen  by 
Dr.  Maurice  H.  Richardson  on  the  20th  of  November.  His  opinion 
was  as  follows:  "The  history  is  suggestive  of  gall-stones  or  thick,  dark, 
tenacious  bile  in  the  gall-bladder.  The  pain  is  probably  due  to  irrita- 
tion and  spasm  of  the  gall-bladder.  I  find  no  physical  signs  of  dis- 
ease. I  advise  an  x-ray  examination  of  the  kidney.  If  this  is  nega- 
tive for  stone  and  other  renal  lesions,  I  advise  exploratory  operation, 
at  which  I  should  expect  to  find  a  gall-stone  too  large  to  pass  the 
cystic  duct." 

Discussion. — We  certainly  must  assume  a  large  element  of  arterio- 
sclerosis in  the  pathology  of  this  case.  The  nocturia,  the  slightly 
raised  blood-pressure,  the  vertigo,  and  mental  symptoms  are  best 
explained  in  this  way.  The  question  then  arises  whether  all  the  other 
symptoms,  including  the  abdominal  symptoms,  can  also  be  thus 
explained.  It  must  be  confessed  that  we  have  not  as  yet  any  clearly 
recognizable  picture  of  abdominal  arteriosclerosis  from  the  clinical 
point  of  view.  At  the  postmortem  table  it  often  seems  as  if  there 
must  be  clinical  manifestations  corresponding  to  the  decided  pre- 
dominance of  the  sclerotic  changes  in  the  vessels  of  this  part  of  the 
body,  yet,  as  a  clinical  entity,  abdominal  arteriosclerosis  rests  chiefly 
upon  scattered  observations  by  French  writers  and  has  never  yet  been 
put  upon  a  firm  foundation. 

Dr.  Richardson's  theory  of  gall-stones  was  probably  based  upon 
the  occurrence  of  an  unexplained  epigastric  pain  in  a  stout  elderly 
woman,  but  surely  there  have  been  no  tj^pical  gall-stone  attacks  and 
nothing  to  give  us  any  certainty  of  this  diagnosis.     On  the  other 


3l8  DIFFERENTIAL   DIAGNOSIS 

hand,  gall-stones  are  probably  the  most  frequent  cause  of  vague 
S}Tnptoms  of  this  type  in  a  woman  of  her  age,  and,  in  the  absence  of 
any  other  well  certified  cause,  it  is  perhaps  as  good  a  hypothesis  as 
any  to  follow  up,  especially  as  the  attacks  have  no  relation  to  meals 
and  are  often  nocturnal. 

Her  loss  of  weight  can  be  explained  either  by  the  poor  nutrition 
attendant  upon  her  dyspepsia  or  by  arteriosclerosis. 

I  see  nothing  in  the  case  to  suggest  renal  stone. 

Outcome. — Since  x-ray  proved  negative,  operation  was  done  No- 
vember 23d.  The  gall-bladder  was  found  to  contain  several  stones, 
one  large  stone  being  firmly  fixed  in  the  cystic  duct.  Colorless  fluid 
was  removed  by  aspiration  from  the  gall-bladder,  which  was  then 
removed. 

The  patient  left  the  hospital  in  good  condition,  December  11,  19 10. 
December  15,  1911,  she  wrote  that  she  had  gained  in  weight  and  had 
a  good  appetite,  but  that  pain  had  returned  in  her  left  side,  and  she 
still  vomited  frequently  in  the  morning.  In  May,  191 1,  she  had  some 
trouble  in  her  back,  for  which  a  corset  belt  was  prescribed  in  the 
Orthopedic  Out-patient  Department.     This  she  has  worn  since. 

In  November,  191 2,  she  had  a  dull,  steady  ache  near  the  heart 
and  under  the  left  shoulder-blade.  There  was  no  vomiting  except 
after  hot  water  taken  before  meals,  as  a  rule,  to  cleanse  the  stomach. 
The  water  was  taken  into  the  stomach  and  rejected,  bitter.  Consti- 
pation was  extreme,  requiring  laxatives  constantly.  She  bled  much 
at  times  from  the  rectum,  sometimes  had  to  wear  a  napkin.  Com- 
plained of  vertigo  and  queer  feehngs  as  if  she  would  fall — as  if  she  were 
walking  on  sponge.  These  were  accompanied  by  precordial  and 
wrist  pains,  especially  on  hurrying.  She  was  confused  and  dis- 
oriented at  times,  bwt  much  better  in  most  ways.  Examination 
showed  a  blood-pressure  of  160  and  the  aortic  second  sound  ac- 
centuated. At  this  time  arteriosclerosis,  cerebral  and  cardiac,  was 
evident.     No  evidence  of  other  disease. 

Case  127 

A  butcher  of  forty-seven  entered  the  hospital  November  6,  1910. 
His  family  history  and  past  history  were  negative.     Habits  good. 

Three  months  ago  he  began  to  have  sour  stomach  and  to  vomit 
about  ten  minutes  after  every  meal.  Constipation  was  troublesome. 
Appetite  was  absent,  so  that,  though  he  continued  at  work,  he  would 
eat  almost  nothing  for  two  or  three  days  at  a  time  and  lose  flesh 
rapidly.     After  two  or  three  weeks  he  got  his  bowels  regulated  with 


DYSPEPSIA  319 

the  aid  of  Epsom  salts.  He  then  felt  much  better,  and  gained  in 
weight  and  strength  during  the  following  three  weeks.  After  that  he 
has  been  gradually  running  down  again  up  to  the  present  time. 

The  physical  examination  showed  emaciation,  but  was  otherwise 
negative,  except  that  the  heart-sounds  were  somewhat  irregular,  an 
entire  beat  being  skipped  every  four  to  seven  cycles.  There  was  no 
lead  line  and  no  stippling  in  the  red  blood-cells.  The  patient  showed 
distinct  mental  deficiency  with  memory  defect.  In  a  hot  bath  noth- 
ing could  be  felt  in  the  abdomen  and  the  urine  was  negative.  Blood 
showed  red  cells,  3,800,000;  white  cells,  15,000;  hemoglobin,  65  per 
cent.  The  stained  smear  showed  slight  achromia,  but  no  other 
changes  of  importance.  Stools  showed  a  slight  reaction  to  guaiac  on 
about  half  the  examinations.  With  a  6-inch  proctoscope  nothing 
abnormal  could  be  found  in  the  rectum.  Lead  was  found  by  Dr.  Boos 
in  the  stools,  and  examination  of  the  patient's  drinking-water  showed 
in  100,000  parts  0.0086  of  lead. 

During  his  seven  weeks'  stay  in  the  hospital  the  patient  had  no 
fever,  normal  blood-pressure,  and  gained  i^  pounds  in  weight.  He 
complained  during  the  first  ten  days  chiefly  of  paroxysmal  cramps 
in  the  abdomen,  unaccompanied  by  any  distention,  visible  peristalsis, 
or  constipation.  He  ate  everything  that  was  given  him  and  called 
for  more.  Each  morning  he  greeted  the  house  officer  with  the  remark, 
"My  friend,  I  never  felt  better  in  my  Hfe."  On  the  i6th  of  November, 
at  seven  in  the  evening,  the  patient  cried  out  loudly.  His  right  hand 
began  to  twitch  and  the  spasm  followed  up  the  arm  to  the  face,  then 
to  the  arms  and  legs,  and  the  whole  body  became  stiffened  in  convul- 
sions, with  sHght  cyanosis  and  deep  respirations.  He  was  uncon- 
scious for  several  minutes,  but  had  no  disturbance  of  the  sphincters 
and  seemed  practically  all  right  when  he  came  to. 

On  the  20th  he  suffered  again  from  severe  cramps  and  the  abdo- 
men was  slightly  distended.  In  a  subsequent  attack  of  cramps  the 
abdomen  was  rigid.  On  the  nth  peristalsis  was  quite  visible,  and, 
despite  the  patient's  emaciation,  the  belly  was  sHghtly  distended. 
In  the  day  time  he  frequently  slept  with  his  eyes  open.  He  left  the 
hospital  December  2  2d,  without  any  considerable  improvement  in  his 
condition. 

Discussion. — Three  months  of  sour  stomach  and  vomiting,  asso- 
ciated with  emaciation,  abdominal  cramps,  and  visible  peristalsis 
with  anemia  and  blood  in  the  stools — such  a  group  of  data  should 
surely  make  us  investigate  the  stomach  and  bowels  as  carefully  as 
possible  for  evidence  of  mahgnant  disease.   Yet  there  were  indications 


320  DIFFERENTIAL  DIAGNOSIS 

pointing  in  another  direction.  Extrasystoles  and  memory  defects, 
together  with  such  twitchings  and  spasms  as  were  exhibited  during  his 
hospital  stay,  certainly  gave  us  an  inkUng  of  arteriosclerosis,  cerebral 
and  cardiac. 

The  finding  of  lead  by  Dr.  Boos  does  not  seem  to  me  in  any  way 
conclusive  evidence  that  this  patient  was  sufifering  from  lead-poisoning. 
Such  a  supposition  is  perfectly  conceivable,  but  it  is  a  well-known  fact 
that  lead  circulates  throughout  the  bodies  of  many  of  us  quite  unde- 
tected and  harmlessly.  The  same  is  true  of  arsenic,  in  small  amounts. 
The  mere  presence  of  these  metals,  therefore,  is  no  evidence  of  their 
toxic  effect,  and,  in  the  absence  of  any  stippling  in  the  red  cells,  any 
lead  line,  or  any  occupation  leading  to  the  ingestion  of  lead  in  consider- 
able quantities,  it  seems  to  me  we  should  look  elsewhere  for  a  more 
plausible  explanation  of  the  patient's  cramps  and  dyspepsia.  It  is 
certainly  unusual  to  see  lead-poisoning  with  so  fine  an  appetite. 

There  was  hardly  any  symptom  in  the  case  which  might  not  be 
explained  either  by  dementia  paralytica  or  by  sclerosis  of  the  cerebral 
arteries.  The  anemia  would  be  unusual  in  this  connection,  and  the 
patient  is  a  little  young  for  arteriosclerosis.  The  absence  of  a  syph- 
iHtic  history  does  not  seem  to  me  of  any  importance. 

Toward  the  end  of  the  record  we  get  the  definite  observation 
of  visible  peristalsis  in  the  abdomen,  with  some  distention  and  rigid- 
ity. This  is  not  easily  accounted  for  by  any  of  the  hypotheses  thus 
far  considered,  and  I  am  not  able  to  explain  it.  When  the  patient 
was  in  the  hospital  we  were  quite  suspicious  of  a  cancer  in  the  large 
intestine,  but  we  got  no  proof  of  it.  Such  a  growth  would  explain 
the  anemia  and  guaiac-positive  stools,  but  would  not  account  for  the 
mental  symptoms,  the  convulsions,  and  extrasystoles.  It  is  also 
very  unusual  to  see  a  ravenous  appetite  with  any  such  growth.  On 
the  whole,  I  think  arteriosclerosis,  involving  the  heart,  brain,  ab- 
dominal and  peripheral  arteries,  is  the  best  conjecture  that  I  can 
offer. 

Outcome. — The  patient  entered  the  Massachusetts  State  Infirmary 
at  Tewksbury  January  25,  191 2 ;  that  is,  more  than  a  year  after  he  left 
the  Massachusetts  General.  At  Tewksbury  the  provisional  diagnosis 
was  cancer  of  the  stomach,  but  he  was  so  noisy  and  violent  that  he 
was  seen  by  alienists  and  some  psychosis  diagnosed.  He  had  pre- 
viously been  committed  to  an  asylum,  February  17,  191 1.  In  Jan- 
uary, 1912,  he  no  longer  complained  of  severe  abdominal  pain,  though 
he  had  occasional  attacks  of  diarrhea.  He  was  then  cachectic  and 
confined  to  bed  on  account  of  general  weakness. 


DYSPEPSIA  321 

A  year  later,  January  15,  1913,  he  died,  and  there  was  found  a 
diffuse  chronic  peritonitis,  most  marked  about  the  Uver  and  stomach, 
but  also  involving  the  right  lower  quadrant.  The  appendix  was 
normal.  The  right  lung  showed  extensive  tuberculous  infiltration, 
there  being  practically  no  normal  pulmonary  tissue  in  any  part  of  the 
lung.  The  upper  lobe  contained  several  large  cavities.  The  upper 
lobe  of  the  left  lung  was  also  filled  with  cavities,  while  its  lower  lobe 
showed  smaller  ulcerating  areas.  The  kidneys  showed  a  chronic 
nephritis.  There  were  numerous  adhesions  between  the  heart  and 
pericardium  and  some  firm  outgrowths  in  the  mitral  valve.  The  rest 
of  the  organs  were  not  remarkable. 

Remarks. — Presumably,  the  abdominal  symptoms  were  due  to 
the  chronic  peritonitis  just  described.  As  we  have  no  record  of  an 
examination  of  the  brain,  it  is  difficult  to  make  any  definite  statement 
about  this,  but  the  Tewksbury  records  show  that  the  patient  was 
much  more  alcohoHc  than  we  had  gathered  when  he  was  at  the  Massa- 
chusetts General  Hospital,  and  it  seems  quite  probable  that  his 
psychosis  was  due  to  alcoholism.  I  trust  that  the  tuberculosis,  so 
extensive  at  the  time  of  his  death,  had  not  made  much  progress  when 
we  saw  him.     Certainly  we  had  no  idea  of  its  presence. 

Case  128 

A  naval  engineer  of  thirty-one  entered  the  hospital  November  21, 
1910.  Previous  to  November,  1909,  he  was  chief  engineer  of  a  United 
States  scouting  cruiser,  and  for  eighteen  months  was  in  a  position  of 
great  responsibility  and  fatigue.  In  November,  1909,  he  noticed  that 
smoke  did  not  taste  right  to  him.  He  began  to  diet  and  cut  out  his 
daily  beer,  but  two  weeks  later  he  began  to  feel  nauseated  and  occa- 
sionally vomited.  This  time  he  had  the  feeling  of  a  lump  somewhere 
in  his  upper  chest,  and  a  sense  of  indefinite  distress  when  he  spoke  or 
swallowed.  He  was  given  two  months'  sick  leave  and  went  home 
to  Maine,  but  in  February,  19 10,  and  while  on  sick  leave,  he  had  an 
attack  of  nausea  and  vomiting  without  any  known  cause  and  was  in 
bed  seventeen  days,  part  of  the  time  on  rectal  feeding.  He  gradually 
recovered  from  this  attack,  but  still  felt  weak  after  it.  May,  1910, 
was  his  third  attack,  after  he  had  been  on  duty  for  a  month.  In  this 
attack  he  got  great  benefit  from  hypodermic  injection,  the  nature 
of  which  he  does  not  know.  Ten  days  after  he  had  taken  the  test 
of  walking  fifty  miles  in  three  days.  In  June,  August,  and  October, 
1910,  he  also  had  attacks  like  the  others,  feeling  fairly  well  in  the  in- 
terim. 

Vol.  11—21 


322 


DIFFERENTLA.L   DIAGNOSIS 


For  live  or  six  years  he  has  noticed  a  Httle  bright  blood  in  the 
movement  of  the  bowels  and  some  difficulty  in  controlling  the  sphinc- 
ter. In  the  morning  he  also  has  slight  incontinence  of  urine.  At 
irregular  intervals  he  has  sudden,  sharp  pains  in  the  thighs,  knees, 
or  heels,  less  often  in  the  chest  or  arms.  These  pains  may  trouble 
him  for  half  an  hour  or  continue  all  night.  His  best  weight  was  in 
1899,  when  he  weighed  145  pounds.  October,  19 10,  he  weighed  125 
pounds;  now,  133  pounds. 

On  physical  examination  he  was  found  to  be  thin,  nervous,  with 
cold,  moist  hands.  His  pupils  were  sHghtly  non-circular  and  equal. 
The  left  reacted  normally  to  light  and  distance;  the  right,  to  distance 
only.  The  lymph-nodes  showed  sHght  general  enlargement  to  about 
the  size  of  a  pea.  Heart  and  lungs  were  negative,  likewise  the 
abdomen.  Knee-jerks  were  Uvely  and  equal.  The  plantars  normal. 
All  the  superficial  reflexes,  especially  the  abdominal,  seemed  to  be 
abnormally  lively.  There  was  no  Romberg  sign,  but  sHght  hypotonus 
of  the  hamstring  muscles.  No  paralysis  of  the  cranial  nerves,  but  the 
hearing  of  the  left  ear  seemed  to  be  impaired.  No  disturbances  of 
tactile  or  muscular  sensation.  Wassermann  reaction  was  positive. 
The  blood  otherwise  negative,  likewise  the  urine.  Systolic  blood- 
pressure,  140.     No  fever. 

Discussion. — It  is  worth  noting,  first  of  all,  that  in  November, 
1909,  before  any  other  distinctive  symptoms  were  present,  the  patient 
noticed,  as  the  first  deviation  from  the  normal,  that  tobacco  did  not 
taste  right  to  him.  I  have  been  told  this  by  many  a  patient  at  the 
very  beginning  of  his  illness,  long  before  any  other  distinctive  symp- 
toms appeared  to  suggest  disease  of  any  particular  organ.  I  think 
the  disinclination  to  smoke  and  drink  is  often  one  of  the  most  dehcate 
indications  of  the  beginning  of  ill  health.  It  is  not  that  the  patient 
leaves  off  these  habits  as  precautions,  but  that  he  actually  loses  his 
taste  for  them. 

Between  November,  1909,  and  November,  1910,  there  is  a  history 
of  six  attacks,  with  good  health  between  times.  One  of  these  attacks 
was  reheved  by  hypodermic  injection. 

Still  further  back  in  the  history,  some  time  before  he  considered 
himself  in  any  way  indisposed,  we  note  that  there  was  difficulty  in 
controlHng  the  sphincters,  also  some  sharp  pains,  which  remind  us  of 
tabes. 

The  physical  examination  supports  the  theory  mentioned  at  the 
end  of  the  last  paragraph.  We  have  an  Argyll-Robertson  pupil  on 
the  right  side,  a  general  adenitis,  a  positive  Wassermann  reaction,  and 


DYSPEPSIA  323 

abnormal  slackness  of  the  hamstring  muscles  when  the  leg  is  hyper- 
extended  upon  the  chest.  Although  the  knee-jerks  are  normal,  this 
is  abundant  evidence  on  which  to  found  an  inference  of  tabes  dorsalis. 

Gall-stones  are  suggested  by  the  sharp  gastric  attacks  and  the 
reUef  by  morphin,  but  there  are  many  features  in  the  case  which 
cannot  be  thus  explained,  and  with  such  definite  indications  of  organic 
nervous  disease  we  have  no  right,  certainly,  to  suppose  a  merely 
functional  or  dietetic  upset. 

Outcome. — At  this  time  the  patient  stayed  in  the  hospital  only  a 
day  or  two,  but  January  6,  191 1,  he  re-entered,  stating  that  he  had 
been  in  first-rate  condition  since  leaving  the  hospital  before,  but  had 
had  at  times  slight  prickly  sensations  in  the  thighs,  legs,  and  heels. 
To-day  there  is  a  small  area  of  superficial  tenderness  on  the  upper 
front  of  the  right  thigh.  Physical  examination  was  otherwise  as 
before.  January. 9th  he  was  given  "606,"  and  a  few  days  later  left 
the  hospital. 

Case  129 

An  unmarried  girl  of  twenty,  a  mill  hand,  entered  the  hospital 
November  23,  1910,  complaining  of  a  burning  pain  in  the  stomach 
two  or  three  hours  after  meals,  often  relieved  by  vomiting.  She  has 
had  this  pain  for  a  year  and  has  been  disabled  by  it.  It  is  never  re- 
lieved by  eating  or  by  water.  It  often  wakes  her  in  the  night.  She 
has  never  tried  soda  for  it.  The  vomitus  is  green  and  bitter,  but  never 
contains  food  or  blood.  Nine  months  ago  she  was  operated  upon  for 
appendicitis  without  relief  of  her  symptoms.  She  feels  best  when  on 
a  diet  of  milk  and  eggs.  Bowels  are  costive.  Best  weight,  122  pounds, 
at  the  present  time;  six  months  ago,  114  pounds.  When  she  was 
two,  and  again  when  she  was  ten,  she  had  for  some  weeks  difficulty 
in  passing  urine.  This  was  somewhat  relieved  by  hot  fomentations. 
Otherwise  her  past  history,  family  history,  and  habits  are  not  remark- 
able. She  is  a  French  Canadian;  speaks  no  English.  Menses  began 
at  seventeen,  but  have  now  been  absent  for  a  year.  For  most  of  the 
last  year  she  has  been  in  bed,  suffering  from  pain  in  the  head,  back,  and 
legs. 

On  physical  examination  patient  is  well  nourished,  skin  very  dry. 
Hands  cold  and  clammy,  with  eczematous  patches  over  the  knuckles. 
Chest  negative.  Abdomen  shows  shght  tenderness  on  deep  pressure 
in  the  left  flank.  There  is  a  surgical  scar  on  the  right  ihac  fossa. 
The  little  fingers  of  both  hands  cannot  be  straightened  entirely,  and 
there  is  an  apparent  atrophy  of  the  fingers  about  the  proximal  pha- 


324 


DIFFERENTIAL   DIAGNOSIS 


langes  and  some  swelling  of  the  knuckles.  She  attributes  the  condi- 
tion to  being  cut  with  a  sickle  when  harvesting.  There  is  slight 
edema  of  both  ankles  and  both  shins,  which  the  patient  had  noticed 
for  the  last  two, weeks. 

Patient  stayed  five  weeks  in  the  ward  and  failed  to  gain  weight. 
The  blood  and  urine  showed  nothing  abnormal,  and  the  stools  were 
negative  to  guaiac  on  five  examinations,  scattered  throughout  the 
month. 

Discussion. — At  twenty  years  of  age  most  dyspepsias  are  func- 
tional, temporary,  and,  when  they  occur  in  a  girl,  very  dependent 
upon  psychic  causes  or  bad  hygiene.  As  usual  in  such  cases  at  the 
present  day  the  appendix  was  taken  out,  and,  as  usual,  without 
relief.  The  case  is  typical  of  the  most  popular  and  most  signal  abuse 
of  surgery  tolerated  by  the  profession  at  the  present  time.  A  few 
years  ago  a  similar  case  would  have  been  subjected  to  an  operation  for 
suspension  of  a  low  right  kidney,  which  doubtless  was  present,  al- 
though we  had  not  taken  the  trouble  to  record  it.  Ten  years 
earHer  she  might  have  suffered  an  ovariotomy.  Doubtless  it  will 
be  many  years  before  we  shall  rid  ourselves  of  the  curse  of  unneces- 
sary surgery. 

Twelve  months'  cessation  of  menstruation  is  not  so  significant  at 
this  age  as  it  would  be  later  in  Hfe,  and,  when  menstruation  has  been 
established  for  only  a  few  years,  it  needs  but  Httle  depression  of  the 
general  vitaHty  to  suspend  the  function  for  a  number  of  months.  Yet, 
even  at  twenty,  amenorrhea  should  make  us  suspect  serious  disease, 
such  as  tuberculosis,  and  do  our  best  to  exclude  it.  This  was  done 
in  the  present  case,  and  I  do  not  see  that  we  can  profitably  consider 
tuberculosis  any  further. 

A  point  of  great  importance,  it  seems  to  me,  in  the  history  of  this 
case  is  the  simple  statement  that  the  patient  has  been  in  bed  for  most 
of  the  last  year.  In  a  person  not  already  seriously  ill,  such  a  proced- 
ure is  enough  to  produce  very  great  discomfort,  if  not  actual  illness. 
All  our  sensations  are  greatly  magnified  under  those  conditions,  and 
it  needs  a  very  steady  head  and  strong  character  to  keep  us  out  of  the 
clutches  of  a  psychoneurosis,  when  cut  off  by  "rest  in  bed"  from  the 
normal  stimuli  and  interests  of  life.  While  no  positive  diagnosis  can 
be  made  upon  the  facts  given  us  in  this  case,  we  can  say  that  sincere 
and  earnest  effort  has  been  made  to  find  organic  disease  and  that  such 
efforts  have  been  wholly  unsuccessful.  This  did  not  necessarily  mean 
that  we  must  incriminate  the  nervous  system.  Not  all  sick  patients, 
with  a  normal  physical  examination,  have  a  psychoneurosis.     Many 


DYSPEPSIA  325 

of  them  have  chronic  industrial  poisonings.  Many  more  are  subject 
to  chronic  mahiutrition,  due  to  faulty  habits  and  poor  hygiene.  Still 
others  have  been  thrown  off  their  balance  and  put  out  of  normal  con- 
verse with  the  world  by  some  misfortune,  by  some  secret  sorrow,  some 
half-recognized  source  of  worry,  or  of  remorse.  In  other  words,  they 
are  iii  need  of  the  sort  of  help  which  a  social  worker  can  give.  They 
need  to  be  carefully  and  sympathetically  studied  by  some  one  who  is 
used  to  the  commoner  sources  of  trouble  in  girls  of  her  age,  and  can 
gradually  find  and  help  to  remove  the  obstacles  which  for  the  time  have 
incapacitated  them.  In  the  course  of  such  a  study,  the  patient's 
environment,  mental  as  well  as  physical — her  total  environment  so  far 
as  we  can  reach  it— must  be  studied.  This  is  difficult,  sometimes 
impossible,  but  recovery  is  often  out  of  the  question  on  any  other 
terms. 

Outcome. — During  most  of  her  stay  she  had  no  stomach  symp- 
toms. She  vomited  only  once  in  the  five  weeks.  The  treatment 
consisted  mostly  of  massage,  electric-light  baths,  and  Zander  ex- 
ercises. Mild  laxatives,  occasional  doses  of  sodium  bicarbonate  and 
of  veronal  sodium  were  given. 

Case  130 

A  housewife  of  thirty-five,  a  Russian  Jewess,  entered  the  hospital 
December  4,  1910.  Family  history  negative,  and  she  has  always  been 
well  and  strong.  She  has  had  three  children,  the  youngest  six  years 
old,  and  has  done  all  of  the  work  of  her  household  without  fatigue. 
She  has  had  no  special  cause  of  worry  and  has  had  plenty  of  sleep. 
Six  days  ago  she  began  to  be  nauseated  about  10  A.  m.  A  physician 
was  called,  who  gave  castor  oil  and  put  her  to  bed,  where  she  has 
remained  since,  suffering  from  more  or  less  constant  nausea  and 
vomiting,  especially  at  night.  The  sight  of  medicine  makes  her 
worse.  She  has  eaten  nothing  for  six  days,  but  has  been  wholly 
free  from  pain.  Her  vomitus  has  been  green  and  watery,  without 
food  or  blood.     Bowels  moved  daily. 

On  physical  examination  nothing  abnormal  was  detected,  ex- 
cept that  there  was  shght  dulness  and  bronchovesicular  breathing  at 
the  right  apex,  above  and  below  the  clavicle,  as  far  down  as  the 
second  rib.  After  cough  a  few  crackles  were  elicited.  The  systolic 
blood-pressure  was  95.  Vaginal  examination  negative.  The  vomit- 
ing continued  intermittently  until  the  14th  of  December.  X-ray,  No. 
18,341,  showed  slight  but  suggestive  shadows  in  both  lungs,  especially 
the  left.     On  the  19th  she  was  given  subcutaneous  injection  of  tuber- 


326 


DIFFERENTIAL  DIAGNOSIS 


culin,  0.005  gram,  and  showed  the  temperature  reaction  indicated  in 
Fig.  115.  At  entrance  the  urine  showed  an  intense  reaction  for  diacetic 
acid,  but  was  otherwise  negative,  as  was  the  blood.  Stool  showed  no 
guaiac  reaction.. 

Discussion. — This  is  the  history  of  what  we  would  ordinarily 
call  simple  acute  dyspepsia.  It  comes  out  of  a  clear  sky,  as  it  were, 
without  previous  illness,  without  known  cause.  Yet,  on  physical 
examination,  there  is  enough  in  the  lungs  to  hint  strongly  at  pul- 
monary tuberculosis.  The  low 
blood-pressure  and  the  ic-ray  ex- 
amination afford  confirmatory 
evidence.  It  is  noteworthy  that 
in  the  A:-ray  picture  the  left  lung 
appears  more  extensively  in- 
volved than  the  right.  The 
tuberculin  reaction  does  not 
seem  to  me  of  much  importance. 
Almost  any  one  of  her  age  and 
living  in  a  large  city  will  have  a 
positive  tuberculin  reaction,  al- 
though the  size  of  the  dose 
which  produced  this  reaction 
gives  it,  perhaps,  some  signifi- 
cance. 

The  chief  point  of  interest  in 
the  case  is  the  presence  of  gas- 
tric symptoms,  which  may  con- 
ceivably have  had  no  relation  to  the  pulmonary  processes,  but  are 
yet  extraordinarily  common  in  association  with  such  a  process. 

I  may  mention  in  connection  with  this  a  similar  case  in  a  man 
of  forty,  who  came  to  the  hospital  December  5,  1910,  complaining  of 
nothing  whatever  except  pain  in  the  stomach,  so  severe  that  he  could 
take  only  liquids.  He  had  no  loss  of  weight  and  no  cough,  yet  there 
were  well-marked  signs  of  phthisis  at  both  apices  and  down  as  low 
as  the  second  rib  in  front.  There  was,  moreover,  an  old  healed 
tuberculous  process  in  the  lower  third  dorsal  and  first  two  lumbar 
vertebrae. 

Outcome. — She  left  the  hospital  on  December  19,  1910,  and  on 
March  10,  191 1,  Dr.  Cleaveland  Floyd,  of  the  Boston  Consumptive 
Hospital,  reported  that  she  was  doing  very  well  at  home,  under  the 
guidance  of  the  hospital  nurse. 


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Fig.  115. — Chart  of  Case  130. 


DYSPEPSIA  327 


Case  131 


A  cutler  of  forty-six  entered  the  hospital  December  4,  1910.  The 
night  before  he  went  to  bed  feeling  perfectly  well,  after  a  supper  of 
simple  foods,  except  for  two  pig's  feet.  At  four  this  morning  he 
waked  from  sound  sleep  with  a  feeling  of  pressure  in  the  flanks.  At 
the  end  of  an  hour  this  pain  traveled  to  the  median  line  in  front  and 
became  severe  and  constant,  causing  him  to  double  up.  It  did  not 
radiate.  Was  accompanied  by  a  sUght  nausea,  but  no  vomiting. 
The  bowels  had  moved  normally  the  morning  previous.  A  year  ago 
had  an  attack  like  the  previous  one  after  a  meal  of  rather  indigestible 
food,  but  a  movement  of  the  bowels  completely  reheved  him.  Was 
at  work  again  within  thirty-six  hours.  As  a  rule  he  takes  no 
alcohol,  but  several  times  a  year  he  stops  work  and  drinks  until 
he  "sees  cats  and  dogs."  The  last  occasion  was  three  weeks  ago. 
Otherwise  his  past  history,  habits,  and  family  history  are  not  re- 
markable. 

When  examined  he  was  in  considerable  pain.  His  pupils  sHghtly 
irregular,  but  reacting  normally.  No  lead  Hne.  Chest  negative. 
The  whole  right  side  of  the  abdomen,  especially  the  upper  portion, 
was  rigid  and  moderately  tender.  The  knee-jerks  normal,  and  there 
was  no  other  abnormahty.  In  the  course  of  the  afternoon  the  pain 
and  spasm  subsided,  and  next  morning  he  seemed  to  be  well  and  was 
accordingly  discharged. 

Discussion. — Here  is  a  case  which  we  may  (although  with  some 
hesitation)  call  acute  dyspepsia,  meaning  thereby  an  arrest  or  delay 
of  digestion  without  known  cause  and  running  a  short,  afebrile  course 
to  complete  recovery.  Such  a  diagnosis  is  warranted  only  when  the 
patient's  history  and  physical  examination  reveal  absolutely  nothing 
except  the  digestive  attack  itself,  and  when,  moreover,  the  outcome 
of  the  case  supports  this  hypothesis.  I  know  of  no  diagnosis  more 
often  contradicted  by  the  subsequent  outcome  than  that  of  acute 
indigestion.  We  are  constantly  reading  in  the  newspapers  that  so 
and  so  was  seized  at  a  banquet  or  while  making  an  address  with  an 
attack  of  acute  indigestion.  The  statement  practically  never  turns 
out  true.  In  the  great  majority  of  cases  the  attack  is  a  cardiac  or  a 
cerebral  one. 

Outcome. — The  patient  was  seen  November,  191 2,  and  stated  that 
he  had  been  working  steadily  since  he  left  the  hospital.  A  year  ago 
he  had  one  attack  similar  to  that  described  above,  although  it  lasted 
but  a  few  hours  and  went  off  of  itself  as  soon  as  his  bowels  moved. 


328  DIFFERENTIAL  DIAGNOSIS 

This  attack,  he  says,  he  is  quite  sure  was  brought  on  by  overeating. 
"I  am  Uke  a  boy  with  a  stick  of  candy,"  he  said.  He  was  at  work 
again  the  next  morning  and  has  been  perfectly  well^ince. 

Case  132 

J.  C.  E.,  a  pattern  maker  of  seventy,  entered  the  hospital  March 
20,  1911.  Was  formerly  a  hard  drinker,  and  twenty  years  ago  had 
sores  on  his  shins  and  knees.  Later  a  chancre,  but  no  secondary 
symptoms.  Was  never  treated  for  this.  For  the  past  thirty  years 
has  taken  practically  no  alcohol.     Tobacco,  ten  cents  a  week. 

His  present  complaint  is  of  indigestion,  which  has  troubled  him 
more  or  less  for  twenty  years.  An  uncomfortable,  empty  feeling  under 
the  left  ribs  is  present  off  and  on,  but  he  may  be  free  from  it  for  months 
at  a  time.  At  its  worst  this  discomfort  is  never  severe,  and  until 
the  past  few  months  has  never  disabled  him  or  needed  treatment. 
During  these  twenty  years  his  bowels  have  been  regular,  but  the 
daily  movement  has  been  loose.  During  the  past  two  years  he  has 
been  constipated  and  has  taken  agar-agar  and  sodium  phosphate  in  the 
Out-patient  Department,  with  relief.  During  the  past  few  months  the 
bowels  have  moved  only  with  enemata. 

Besides  the  discomfort  above  mentioned,  he  sometimes  has  a 
dull  ache  in  the  abdomen  and  back,  especially  after  a  day's  work  or 
when  he  is  worried.  Food  seems  to  make  no  difference.  The  pain 
never  comes  at  night.  Though  he  has  periods  of  improvement,  often 
lasting  weeks,  on  the  whole,  he  grows  weaker  and  more  miserable. 
Until  the  past  few  weeks  there  has  been  no  vomiting;  since  then  he 
has  often  raised  a  Httle  sour  water  after  periods  of  pain.  A  bowel 
movement  gives  more  rehef  than  anything  else.  Since  last  summer 
he  has  been  unable  to  work.  Five  years  ago  he  weighed  150  pounds. 
Within  the  last  two  years  he  has  lost  weight  and  now  weighs  119 
pounds.  Lavage  by  Dr.  H.  F.  Hewes  last  September  showed  no  food 
residue,  no  positive  guaiac  test  either  in  the  stomach  contents  or  in 
the  stools.  After  a  test-meal  a  free  HCl  was  0.08  per  cent.  The 
family  history  is  negative. 

Physical  examination  showed  a  marked  emaciation.  Good 
color,  normal  pupils,  no  glandular  enlargement.  There  was  a  marked 
depression  at  the  lower  end  of  the  sternum.  The  heart  and  lungs 
negative.  The  abdomen  showed  slight  tenderness  on  deep  epi- 
gastric palpation.  There  was  a  marked  right  inguinal  hernia  and 
slight  left  inguinal  hernia,  otherwise  the  abdomen  is  negative.  The 
right  shin  showed  a  brownish  discoloration.     Reflexes  were  normal. 


DYSPEPSIA  329 

On  the  2ist  the  stomach- tube,  passed  before  breakfast,  showed  a 
few  shreds  of  orange  fiber,  but  no  other  food  residue.  The  capacity 
of  the  stomach  was  1900  c.c.  On  inflation,  the  lower  border  came  just 
below  the  navel,  the  upper  border  at  the  ensiform.  After  an  Ewald 
meal  the  stomach  contents  showed  a  faint  guaiac  reaction  and  free 
HCl  0.04  per  cent.;  total  acidity,  0.07  per  cent.  On  the  24th  there 
was  a  very  considerable  food  residue  before  breakfast.  Free  HCl 
0.07  per  cent.;  guaiac  test  negative.  It  was  difficult  to  wash  the 
stomach  clean  on  this  or  on  subsequent  attempts.  Guaiac  test  was 
positive  in  the  stool  of  March  24th,  though  negative  two  days  pre- 
viously. 

Discussion. — Points  of  interest  in  this  case  are:  (i)  The  history  of 
twenty  years'  gastric  discomfort  upon  a  basis  of  alcoholism  and 
possible  syphilis.  (2)  The  fact  that  throughout  the  illness  pain  has 
been  comparatively  slight.  (3)  The  negative  stomach  examination 
seven  months  ago,  although  at  the  present  time  his  stomach  shows 
obvious  evidence  of  stasis.  (4)  The  presence  of  HCl  in  the  gastric 
contents.  (5)  The  negative  physical  examination,  except  for  the 
evidence  of  emaciation,  which  apparently  has  been  going  on  for  two 
years. 

In  a  man  of  seventy  such  history  certainly  justifies  us  in  surmis- 
ing that  gastric  cancer  is  present.  At  the  same  time  we  must  remem- 
ber that  renal  insufficiency  (that  is,  uremia  or  its  equivalent),  gall- 
stones, arteriosclerosis,  or  cirrhotic  liver  might  produce  the  same 
troubles. 

The  physical  condition  seems  to  be  fairly  good  despite  the  marked 
emaciation,  and  it  seems  to  me  that  he  has  a  right  to  exploratory 
incision  for  possible  gastric  cancer. 

Outcome. — On  the  30th  of  March  Dr.  G.  W.  W.  Brewster  advised 
exploration,  which  revealed  a  mass  just  above  the  pylorus,  and  ex- 
tending along  the  lesser  curvature  nearly  to  the  cardia.  The  mass 
at  the  pylorus  was  the  size  of  a  hen's  egg.  Posterior  gastro-enteros- 
tomy.  Patient  made  a  good  recovery,  and  left  the  hospital  on  the 
13  th  of  April  with  the  wound  well  healed  and  with  a  considerable 
gain  in  weight.  Seen  May  19,  191 2.  States  that  since  leaving  the 
hospital  has  been  in  good  health  and  gaining  weight,  up  to  about 
four  weeks  ago.  He  has  not  vomited  at  all.  For  the  last  four  weeks 
he  has  been  having  severe  pain  in  the  left  loin  and  back.  A  tumor 
the  size  of  two  fists  is  now  palpable  in  the  epigastrium  and  to  the 
left  of  it.     The  patient  is  now  losing  weight. 

Remarks. — It  is  notable  that  the  patient  had  at  least  a  year  of 


330 


DIFFERENTIAL  DIAGNOSIS 


good  health  and  gain  in  weight.  Presumably  within  the  last  four 
weeks  the  growth  has  begun  to  progress,  but  it  seems  to  me  clear  that 
the  gastro-enterostomy  was  well  justified. 

Case  133 

A  bacteriologist  of  forty-three  entered  the  hospital  April  6,  191 1. 
He  states  that  he  has  always  been  below  his  proper  weight  in  spite  of 
careful  and  long-continued  efforts  to  raise  it.  His  digestion  is  capri- 
cious and  uncertain.  Eggs,  fish-chowder,  oysters,  and  creamed  soups 
have  been  hard  to  get  in  and  easy  to  get  out  of  his  stomach  for  a  num- 


As  • «    ba  c  V^ 


fi'lbert- 
So^t-  V.OT 


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Voit-t  •»- 
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Cv-acWJcs 


Fig.  116. — Chest  signs  in  Case  133. 

ber  of  years.  For  the  last  four  years  he  has  had  pain  following  any 
acid  food.  Meats  agree  with  him  well.  If  he  eats  rapidly  he  gets  in 
more  food  than  if  he  stops  to  talk  between  times,  and  chiefly  on  this 
account  he  has  found  it  impracticable  to  dine  in  company.  He  says 
that  he  has  not  eaten  a  square  meal  for  years,  partly  from  lack  of 
appetite  and  partly  from  fear  of  consequences. 

As  a  rule,  he  wakes  up  about  4.30  a.  m.  very  hungry.  Hunger 
ripens  into  epigastric  pain  if  he  does  not  get  breakfast  by  8  a.  m. 
He  has  some  epigastric  pain  all  the  morning,  and  by  1 1 .45  it  is  severe. 
If  lunch  is  prompt  he  gets  rehef  from  food,  but  if  it  is  delayed,  a  pain 


DYSPEPSIA 


331 


as  sharp  as  toothache  in  the  epigastrium  causes  distaste  for  all  food. 
After  lunch  he  has  a  sense  of  weight,  which  gradually  develops  into 
pain  and  bothers  him  all  the  afternoon.  After  an  early  supper  he  goes 
to  bed  and  to  sleep.  He  is  rather  chagrined  to  be  obliged  to  state 
that  immediate  sleep  prevents  the  completion  of  the  history  of  his 
pains  for  the  day. 

In  December,  1909,  he  had  a  pulmonary  hemorrhage  after  the 
inhalation  of  the  fumes  of  hot  glacial  acetic  acid.  During  the  next 
two  weeks  there  were  several  more  hemorrhages,  2  or  3  ounces  at  a 
time.     Associated  with  these,  there  was  a  slight  cough.     Dr.  J.  J. 


j)o  \\  -     prt>yr\- 
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browcUiixl   brearh 
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Dull  -  - 

voice  (i.y\^ 


Fig.  117. — Chest  signs  in  Case  133. 

Goodale  examined  him  at  this  time  and  found  varices  at  the  base 
of  the  tongue. 

At  the  same  time  of  these  hemorrhages  the  patient  had  also 
three  attacks  of  hematemesis,  about  8  ounces  in  amount,  with  tarry 
stools.  He  was  quite  sure  that  this  blood  was  not  previously  swal- 
lowed. 

Since  June,  1909,  he  has  done  no  work,  as  he  had  at  that  time 
a  heat-stroke  and  has  had  irregular  fever  ever  since.  Most  of  last 
winter  he  was  in  bed,  apparently  because  that  was  the  only  warm 
place  he  could  find. 

His  family  history  is  excellent. 


332 


DIFFERENTIAL   DIAGNOSIS 


Physical  examination  shows  emaciation,  flushed  face,  sHght  cyano- 
sis, chest  as  in  Figs.  ii6  and  117.  Pulmonic  second  sound  sharply 
accentuated.  Apex  first  sound  reduplicated.  Heart  otherwise  nega- 
tive, likewise  the  rest  of  the  visceral  examination.  The  blood  shows 
a  leukocytosis  of  15,000  to  19,500.  Range  of  temperature  shown  in 
Fig.  118.     Stomach-tube  reveals  no  fasting  contents.     A  test-meal  was 

not  given,  as  his  stomach  improved  rapidly 
under  a  diet  of  liquids  and  soft  solids. 
He  was  soon  changed  to  a  normal  diet. 

Discussion. — The  nature  of  the  varie- 
gated dyspepsia  from  which  this  patient 
has  suffered  for  four  years  ought  to  have 
been  clear  long  ago,  when  it  was  known 
that  he  has  been  having  fever  for  at  least 
two  years,  yet  it  is  clear  from  the  way 
in  which  the  history  was  given  that  the 
pulmonary  hemorrhage  of  December,  1909, 
was  not  at  once  recognized  for  what  it 
must  have  been,  namely,  an  evidence  of 
pulmonary  tuberculosis,  but  was  faultily 
connected  with  the  inhalation  of  acid 
fumes.  The  fumes  may  have  started  the 
patient  to  coughing,  but  the  hemorrhage 
Fig.  ii8.-Chart  of  Case  133.  ^^s  undoubtedly  of  tuberculous  origin. 
The  same  fatuous  eagerness  to  avoid  facing  the  facts,  and  to  snatch 
at  any  explanation  other  than  the  obvious  one,  is  shown  in  the  impor- 
tance attributed  to  finding  dilating  varices  at  the  base  of  the  tongue. 
Such  findings  are  not  uncommon  when  people  are  trying  with  all  their 
might  to  bHnd  themselves  to  the  existence  of  pulmonary  tuberculosis. 
There  is  some  doubt  as  to  the  origin  of  the  blood  vomiting.  The 
patient  may  be'  right  in  supposing  that  he  had  not  previously  swal- 
lowed the  blood,  but  I  do  not  feel  nearly  as  sure  upon  this  point  as 
he  did.  There  can  be  no  reasonable  doubt  of  the  diagnosis  in  this 
case,  but  to  me  the  point  of  chief  interest  is  the  rapid  improvement 
following  the  administration  of  a  good  deal  more  food  than  the  patient 
had  believed  himself  able  to  take.  As  in  so  many  other  cases,  dys- 
pepsia is  due  to  starvation  and  starvation  to  dyspepsia.  Break  the 
circle  by  forced  feeding,  despite  discomfort,  and  we  soon  get  back  to 
normal  digestion. 

Outcome. — Tubercle  bacilli  were  abundant  in  the  sputum.  Stools 
were  always  negative  to  guaiac. 


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DYSPEPSIA  333 


Case  134 


A  rivet  driller  of  forty-nine  entered  the  hospital  May  26,  191 1. 
Twelve  years  ago  the  patient  was  troubled  with  indigestion  for  a  week, 
otherwise  he  has  been  well  all  his  life  until  his  present  illness,  despite 
the  fact  that  he  smokes  and  chews  thirty  cents'  worth  of  tobacco  a 
week.  His  family  history  is  negative.  For  the  past  year  he  has  been 
troubled  more  or  less  by  indigestion,  showing  itself  in  gas  and  epi- 
gastric distress  one-half  to  one  hour  after  food,  relieved  by  belching  of 
gas  or  by  vomiting.  He  has  never  tried  soda  or  food  for  relief.  The 
onset  of  this  trouble  was  rather  sudden,  and  it  has  grown  neither 
better  nor  worse.  He  is  never  free  from  it  more  than  a  few  days  at  a 
time.  He  never  has  vomited  any  blood  or  coffee-ground  material, 
but  only  food  recently  eaten.  His  bowels  have  been  constipated 
throughout  the  year  of  his  trouble  with  indigestion,  though  they  had 
never  been  so  previously.  In  February,  191 1,  he  did  not  feel  up  to 
his  work,  but  he  kept  at  it  until  a  month  ago,  when  increasing  weak- 
ness and  lack  of  ambition  compelled  him  to  desist.  He  first  came  to 
the  Out-patient  Department  on  account  of  stiffness,  lameness,  and 
swelling  of  his  feet.     He  has  no  other  complaints. 

Physical  examination  showed  poor  nutrition,  but  was  otherwise 
negative.  Systolic  blood-pressure,  120.  Urine  negative.  Stools 
negative  to  guaiac  on  six  examinations  and  free  from  any  abnormal 
constituents.  Red  cells,  1,600,000;  white  cells,  6000;  hemoglobin, 
50  per  cent.  Blood-plates,  196,000.  Differential  count  normal. 
The  stained  specimen  showed  many  large  and  well-stained  red  cells 
and  a  few  that  were  achromic,  marked  variations  in  size  and  shape, 
occasionally  an  off-colored  or  stippled  cell.  Four  normoblasts  were 
seen  while  counting  200  whites.  Wassermann  reaction  was  negative. 
The  patient  stayed  two  weeks  in  the  hospital  and  improved  consider- 
ably in  all  respects,  his  red  cells  rising  to  2,500,000,  hemoglobin  70 
per  cent,  during  that  period.     On  the  8th  of  Jime  he  left  the  hospital. 

Discussion. — There  is  nothing  characteristic  in  the  history, 
although  at  his  age  any  abruptly  appearing  dyspepsia  threatens 
cancer.  It  is,  however,  rather  suggestive  that  when  he  gave  up  work 
it  was  on  account  of  weakness  and  not  for  any  other  reason.  This 
state  of  things  is  especially  apt  to  be  associated  with  a  blood-count  like 
that  recorded  in  the  physical  examination;  in  other  words,  with  per- 
nicious anemia,  of  which  that  blood-picture  is  almost  typical. 

It  has  been  repeatedly  said  in  text-books  and  elsewhere  that  gastric 
cancer  not  infrequently  is  associated  with  a  blood-picture  indistinguish- 


334 


DIFFERENTIAL  DIAGNOSIS 


able  from  that  of  pernicious  anemia,  and,  doubtless,  in  rare  cases  this 
must  be  true,  since  it  has  been  believed  by  excellent  observers,  but 
in  my  own  twenty  years  of  observation  of  pernicious  anemia  and  of 
gastric  cancer  I  have  never  known  a  case  in  which  a  mistake  was 
made.  Indeed,  in  comparison  with  the  frequency  of  mistaken  diag- 
nosis in  other  diseases — a  frequency  on  which  I  have  insisted^ — it 
seems  to  me  very  notable  how  rarely  one  makes  any  such  mistakes  in 
differential  diagnosis  involving  pernicious  anemia  as  one  of  the  dis- 
eases considered.  Prior  to  autopsy  in  such  cases  I  have  repeatedly 
made  positive  statements  as  to  what  would  be  found  by  the  pathologist 
— statements  which  I  should  not  be  willing  to  make  regarding  any 
other  disease. 

Case  135 

An  Irish  housewife  of  fifty-six  entered  the  hospital  July  i,  1911. 
The  patient  has  always  been  well  until  the  winter  of  1910  and  191 1, 
when  she  noticed  that  she  became  easily  tired  when  at  work.  She 
had  had  no  previous  illnesses  and  had  an  excellent  family  history. 
For  the  past  three  months  she  has  had  epigastric  distress,  coming  an 
hour  or  two  after  eating  and  lasting  from  two  to  four  hours.  It  comes 
especially  after  eating  potatoes  or  other  heavy  vegetables.  She  never 
vomits  and  has  noticed  no  jaundice  or  blood  in  the  stools,  but  her  epi- 
gastric distress  is  constantly  aggravated. 

For  the  same  period  she  has  been  losing  strength  and  weight,  about 
20  pounds  in  all,  she  thinks.  She  has  also  had  a  great  deal  of  sweating 
and  a  dull,  heavy  feeling  at  the  top  of  her  head. 

Physical  examination  shows  good  nutrition,  normal  pupils,  glands, 
and  reflexes.  Chest  negative,  save  for  a  soft  systolic  murmur  follow- 
ing the  first  sound  at  the  apex,  and  not  transmitted.  The  liver  dulness 
extends  from  the  fourth  interspace,  mammary  line,  to  a  point  3  cm. 
below  the  ribs,  where  a  smooth,  tender,  rounded  edge  is  felt.  The 
splenic  dulness  is  increased,  and  the  spleen  is  palpable  and  very 
slightly  tender.  It  extends  into  the  left  flank  and  can  be  felt  bi- 
manually  (Fig.  119).  Urine  negative.  No  fever  in  two  weeks' 
observation.  Systolic  blood-pressure,  120.  Fundi  normal.  Stools 
negative.  The  blood  shows  reds,  5,000,000;  whites,  212,000;  hemo- 
globin,  100  per  cent.     The  differential  count  showed  polynuclears, 

^  "Diagnostic  Pitfalls  Identified  During  a  Study  of  Three  Thousand  Autopsies," 
R.  C.  Cabot,  Jour.  Amer.  Med.  Assoc,  December  28,  191 2,  vol.  lix,  pp.  2295-2298;  "A 
Study  of  Mistaken  Diagnoses,"  R.  C.  Cabot,  Jour.  Amer.  Med.  Assoc,  October  15,  1910, 
vol.  Iv,  pp.  1343-1350- 


DYSPEPSIA 


335 


44  per  cent.;  myelocytes,  47  per  cent.;  eosinophils,  2  per  cent.;  mast- 
cells  and  basophilic  myelocytes,  4  per  cent. ;  transitional  forms,  2  per 
cent.  Ten  normoblasts  and  one  megaloblast  seen  while  counting  500 
cells.  The  red  cells  show  no  changes  except  rarely  a  little  fine  stip- 
pHng.     Blood-plates,  572,000. 

Discussion. — The  cause  of  this  woman's  three  months'  dyspepsia, 
with  emaciation  and  sweats,  could  never  have  been  found  without  a 
general  physical  examination  of  the  kind  that  many  physicians  rarely 
make  in  an  ofhce  visit,  because  of  the  waste  of  time  involved  in  getting 
rid  of  corsets  and  other  impediments.     The  case  is  typical  of  many 


Fig.  119. — Physical  signs  in  Case  135. 


others  in  which  diagnosis  is  so  easy  as  to  be  almost  inevitable,  provided 
we  make  a  general  physical  examination,  but  wholly  impossible  if  we 
neglect  this  procedure.  As  soon  as  the  spleen  was  felt  (and  it  could 
hardly  have  been  missed  by  anyone  who  went  through  with  the 
routine  procedures  of  abdominal  examination)  it  would  naturally 
occur  to  any  educated  physician  to  examine  the  blood,  which,  in  turn, 
would  lead  straight  to  the  diagnosis  of  myeloid  leukemia. 

Outcome. — The  patient  was  given  aj-ray  treatment,  and  showed  a 
fair  degree  of  improvement  during  the  two  weeks  of  her  stay.  She 
left  the  hospital  on  the  15th  of  July. 


336  DIFFERENTIAL  DIAGNOSIS 

Case  136 

An  Irish  housemaid  of  thirty-nine  entered  the  hospital  August  10, 
191 1,  after  considerable  study  in  the  Out-patient  Department.  For 
the  past  year  she  has  been  troubled  almost  constantly  by  flatulence 
and  slight  epigastric  distress,  coming  either  directly  after  meals  or  an 
hour  or  two  later,  reheved  by  soda  or  by  hot  water,  which  expelled  gas. 
There  has  been  no  vomiting,  no  nausea,  no  pain,  no  loss  of  weight,  and 
no  weakness.  In  the  Out-patient  Department  her  case  was  studied  by 
Dr.  F.  T.  Lord  and  no  evidence  of  stasis  found.  The  guaiac  reaction 
was  sKghtly  positive  in  the  wash-water  before  breakfast  and  no  free 
HCl  was  found  after  a  test-meal. 

For  three  months  her  symptoms  have  been  aggravated,  and  have 
consisted  chiefly  of  pain  and  vomiting.  The  pain  is  in  the  epigas- 
trium, extending  to  the  left  axilla  and  back.  It  is  sharp  and  cutting, 
comes  within  a  very  few  minutes  after  the  taking  of  any  food,  liquid 
or  soUd.  It  is  intermittent,  the  sharp  attacks  lasting  not  over  five 
minutes  and  being  relieved  by  belching.  In  the  intervals  between 
these  attacks  there  is  a  sense  of  epigastric  soreness. 

The  vomiting  which  began  three  months  ago  has  gradually  in- 
creased in  frequency.  Now  she  vomits  after  almost  every  meal.  The 
vomitus  is  small  in  amount,  white  or  greenish,  never  dark  or  blood 
stained,  and  never  containing  food  eaten  the  day  before.  Throughout 
the  day  and  night  she  belches  large  quantities  of  gas.  The  bowels  are 
no  more  constipated  than  they  have  been  all  her  life.  A  year  ago  she 
weighed  135  pounds,  and  until  the  last  three  months  she  thinks  there 
was  no  loss  of  weight.  Since  then  she  believes  she  has  lost  25  pounds, 
together  with  much  color,  and  has  become  very  weak.  For  three 
weeks  she  has  been  unable  to  work.  Her  appetite,  formerly  very 
good,  has  failed  during  the  last  two  months,  and  for  five  weeks  she  has 
eaten  scarcely  anything.     There  has  been  no  jaundice. 

The  patient  is  emaciated  and  slightly  pale,  skin  very  dry.  Pupils 
and  mouth  negative.  Over  the  left  clavicle  are  a  few  small  painless 
glands.  There  is  marked  suppuration  at  the  roots  of  the  teeth,  which 
are  in  very  poor  condition.  The  chest  is  negative.  The  abdomen  is 
relaxed,  and  shows  just  above  the  umbilicus  in  the  middle  line  a  small 
rounded  mass,  moving  slightly  with  respiration  and  moderately  tender 
(Fig.  120).  The  outlines  of  the  stomach  by  auscultatory  percussion 
are  shown  in  the  same  diagram.  The  reflexes  and  pelvic  examination 
were  negative  except  for  moderate  chronic  thickening  in  both  culde- 
sacs.     Blood-pressure,  no  mm.  Hg.     Blood  and  urine  normal.     No 


DYSPEPSIA 


337 


fever  in  four  days'  observation.  The  stomach-tube  is  easily  passed 
for  a  distance  of  49  cm.  Attempts  to  pass  it  further  are  unsuccessful 
and  cause  pain.  No  fasting  contents  are  obtained.  After  a  test-meal, 
which  was  vomited,  the  vomitus  contains  no  free  HCl.  The  gastric 
capacity  was  not  measured.  Well-marked  visible  peristalsis  is  ob- 
served. The  patient  continued  to  vomit  frequently  during  the  four 
days  of  her  stay  in  the  medical  wards,  free  HCl  being  always  absent  in 
the  vomitus.  The  diagnoses  considered  were  gastroptosis,  gastric 
stasis,  and  cancer  of  the  pylorus  and  cardia. 


Fig.  120. — Signs  detected  in  Case  136. 

Discussion. — Although  this  patient  is  only  thirty-nine,  and  al- 
though the  amount  of  pain  which  she  has  suffered  is  greater  than  that 
which  we  usually  see  in  gastric  cancer,  the  fact  that  she  now  has  a  pal- 
pable epigastric  mass  (Fig.  120)  and  has  lost  25  pounds'  w^eight  within 
three  months,  must  surely  make  us  very  apprehensive  of  cancer, 
especially  with  a  positive  guaiac  test  and  no  HCl  in  the  gastric  con- 
tents on  repeated  tests.  The  fact  that  the  stomach-tube  w^ould  pass 
no  farther  than  49  cm.  from  the  teeth  is  evidence  that  the  growth 
involves  the  cardiac  orifice  of  the  stomach,  but,  in  all  probabiHty, 
it  is  not  confined  to  that  region,  since  we  observed  peristalsis,  appar- 

VoL.  11—22 


338  DIFFERENTIAL   DIAGNOSIS 

ently  gastric  in  origin.  Such  peristalsis  usually  means  pyloric  ob- 
struction, although  in  a  very  thin  person  it  may  sometimes  be  ob- 
served with  a  normal  pylorus.  Further  evidence  pointing  toward  an 
obstructed  pylo-rus  is  the  great  dryness  of  the  skin. 

With  pyloric  stenosis,  water  is  not  passed  into  the  intestine  as  it 
should  be,  and,  as  water  is  not  absorbed  in  the  stomach,  the  tissues 
become  abnormally  desiccated.  This  should  always  be  remembered 
when  we  note  striking  drj-ness  of  the  skin  in  a  patient  complaining  of 
any  gastric  symptoms. 

A  point  of  notable  interest  in  the  case  (provided  that  I  am  correct 
in  the  diagnosis  of  gastric  cancer)  is  the  preservation  of  a  good  appetite 
until  the  last  two  months  before  she  came  under  observation. 

Outcome. — Bismuth  a;-ray,  August  14th,  showed  dilatation  of  the 
lower  end  of  the  esophagus  and  obstruction  of  the  cardiac  orifice. 
On  the  1 6th  Dr.  Scudder  opened  the  abdomen  and  found  a  hard 
nodular  mass  along  the  lesser  curvature,  most  noticeable  at  the  cardiac 
end.  The  pylorus  was  patent  and  normal.  No  liver  nodules  were 
made  out.  An  opening  was  made  in  the  anterior  wall  of  the  stomach, 
3  inches  above  the  pylorus,  a  soit  rubber  tube  was  introduced,  and  the 
wound  closed  around  the  tube.  The  patient  did  very  well  after  opera- 
tion until  about  the  first  of  September,  when  she  began  to  lose  ground 
despite  the  attempt  to  nourish  her  through  the  tube.  She  was, 
accordingly,  discharged.     Three  months  later  she  died  at  her  home. 

Case  137 

A  school-teacher  of  thirty-two  entered  the  hospital  September  23, 
191 1.  Her  father  died  of  tuberculosis  three  years  ago,  and  was  taken 
care  of  by  the  patient  some  months  before  death.  The  mother  also 
died  of  tuberculosis  last  May,  and  was  also  taken  care  of  by  the 
patient.  One  maternal  uncle  died  of  the  same  disease.  Four  brothers 
and  four  sisters  are  living  and  well.  Patient  has  been  well  until  four 
years  ago,  when,  during  a  period  of  very  hard  work,  she  began  to  have 
attacks  of  "stomach  trouble,"  characterized  by  epigastric  pain, 
moderately  severe,  not  radiating,  coming  most  often  before  breakfast 
and  somewhat  relieved  by  food.  The  attacks  were  accompanied  by 
i]atulence,  but  not  by  vomiting. 

These  attacks  come  when  she  is  especially  overtired  and  last  one 
or  two  weeks.  For  the  last  two  years  she  has  noticed  a  very  gradual 
loss  of  strength,  though  she  has  continued  to  do  her  work  with  occa- 
sional "days  off."  During  the  last  two  years  she  has  had  occasional 
"breathless  spells,"  varying  from  half  an  hour  to  a  day  in  length. 


DYSPEPSIA 


339 


The  slightest  exertion  makes  her  very  weak  and  short  of  breath  at 
these  times.  These  spells  have  increased  in  frequency  of  late.  There 
has  been  no  edema  except  from  varicose  veins  and  when  she  has 
been  standing  all  day.  She  has  had  grumbling  pain  in  the  lumbar 
region,  ascribed  to  much  walking.  During  the  past  summer  there 
have  been  occasional  "fainting  spells,"  in  which  she  prevents  a  com- 
plete loss  of  consciousness  by  quickly  lying  down.  During  this  same 
period  singing  and  buzzing  noises  in  her  ears  have  also  troubled  her. 
Her  bowels  are  habitually  constipated.  She  has  had  no  cough  and  no 
sputum  at  any  time.  She  has  kept  steadily  at  work  until  five  days  ago, 
when,  without  known  cause,  she  began  to  vomit,  and  has  not  since 
been  able  to  retain  any  food. 
Her  best  weight,  132  pounds,  was 
a  year  ago,  biit  she  thinks  she  has 
lost  somewhat  since  that  time. 

Physical  examination  showed 
the  patient  poorly  nourished  and 
looking  sick.  The  face  and  neck 
showed  marked  brown  pigmen- 
tation and  the  skin  of  the  body 
Vv^as  generally  dark.  Patient  in- 
sists that  she  has  always  been 
"almost  as  dark  as  now  and  that 
last  spring  she  was  much  darker." 
Later  she  admitted  that  the 
lower  part  of  her  body  had 
definitely,  but  very  gradually, 
been  growing  darker  during  the 
past  year.  The  lower  part  of 
the  sternum,  where  the  corset 
presses,  was  more  deeply  pigmented  than  elsewhere,  except  in  the 
axillae  and  groins.  The  pupils  slightly  irregular,  otherwise  normal. 
There  was  no  pigmentation  in  the  mouth. 

The  heart's  impulse  was  not  seen  or  felt,  but  its  sounds  were  best 
heard  in  the  fifth  space,  9.5  cm.  from  midsternum.  There  was  no 
enlargement  on  the  right.  The  apex  first*  sound  was  distinct,  re- 
duplicated, and  accompanied  by  a  faint  systolic  murmur,  not  trans- 
mitted. There  was  no  accentuation  with  the  pulmonic  second.  Lungs 
and  abdomen  showed  nothing  abnormal.  Reflexes  were  normal. 
There  were  moderate  varicose  veins  in  the  left  lower  leg.  Blood- 
pressure  was  85  mm.  Hg.  systolic,  68  mm.  Hg.  diastolic,  and  during 


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Fig.  121.— Chart  of  Case  137. 


340  DEFFERENTIAL   DIAGNOSIS 

her  month's  stay  in  the  hospital  the  systohc  pressure  ranged  dose 
to  80  (Fig.  121).  Blood  showed  red  cells,  4,960,000;  white  cells, 
10,000;  hemoglobin,  80  per  cent.  The  stained  smear  showed  slight 
achromia.  The  polynuclear  cells,  49  per  cent. ;  lymphocytes,  49  per 
cent.;  eosinophils,  2  per  cent.  The  urine  averaged  25  ounces  in 
twenty-four  hours;  specific  gravity,  loio  to  1012.  Trace  of  albumin 
was  always  present,  and  in  the  sediment  there  were  many  hyaline 
and  finely  granular  casts  with  cells  or  fat  adherent.  At  three  exam- 
inations the  feces  were  in  every  way  negative. 

The  vomiting  was  controlled  by  limiting  the  nourishment  to 
liquids  in  very  small  amounts,  i  to  2  teaspoonfuls  at  a  time,  given 
frequently.  Meantime  6  ounces  of  normal  saline  solution,  contain- 
ing 15  per  cent,  glucose,  were  injected  every  six  hours  by  rectum. 
Iced  champagne  in  small  amounts  helped  to  relieve  her.  Later, 
albumin-water,  oatmeal  gruel,  toast,  and  minced  chicken  were  added. 
She  ceased  vomiting  the  day  after  entrance  and  gained  somewhat 
in  strength.  By  October  3d  she  was  eating  meat  and  vegetables, 
and  was  able  to  sit  up  with  a  bed-rest  and  read  a  Httle.  Up  to  the 
i6th  of  October  she  seemed  to  be  gaining,  sat  up  out  of  bed,  and  was 
cheerful.  On  the  i6th  nausea  began  again  and  could  not  be  checked. 
By  midnight  on  the  i8th  she  was  pulseless  and  completely  exhausted. 
At  2  A.  M.  she  went  into  a  stupor  and  at  7  a.  m.,  October  i8th,  died. 

Discussion. — A  family  history  of  tuberculosis,  four  years'  trouble 
with  dyspepsia,  two  years'  suffering  with  cardiac  attacks,  and  three 
months  during  which  the  patient  has  been  subject  to  fainting  spells — 
such  data  lead  us  to  look  carefully  for  any  evidence  of  Addison's 
disease,  and,  despite  her  statement  that  her  skin  has  always  been 
brown,  despite  the  absence  of  pigmentation  in  the  mouth,  we  can 
hardly  fail  to  interpret  the  discoloration  of  the  skin  and  the  low  blood- 
pressure  as  confirmatory  evidence  of  Addison's  disease.  This  holds 
good  despite  the  fact  that  the  brownish  areas  are  more  marked  where 
the  corsets  bring  pressure. 

The  only  question  which  seems  to  me  deserving  of  further  discus- 
sion is  this:  Has  she,  in  addition  to  her  Addison's  disease,  any  nephri- 
tis? The  urine  has  a  notably  low  specific  gravity,  but  this  may  very 
possibly  be  accounted  for  by  deficiency  of  sohds,  especially  of  pro- 
teins, in  her  nutrition.  The  number  of  casts  is  somewhat  greater 
than  that  ordinarily  seen  in  the  urine  of  Addison's  disease,  and  one 
might  well  conjecture  that  some  amyloid  disease  of  the  kidney  is 
present,  were  it  not  for  the  fact  that  amyloid  disease  is  usually  asso- 
ciated with  those  forms  of  tuberculosis  which  involve  chronic  sup- 


DYSPEPSIA  341 

puration.  We  have  nothing  to  suggest  any  such  suppuration  in  this 
case. 

If  the  diagnosis  is  Addison's  disease,  we  have  in  the  family  history 
a  reason  for  beheving  that  the  adrenals  are  tuberculous. 

Outcome. — Autopsy  No.  2940  showed  Addison's  disease,  but  no 
nephritis.  The  cortices  of  the  adrenals  were  very  atrophic,  but  there 
was  no  tuberculosis. 

Case  138 

A  housewife  of  twenty-nine  entered  the  hospital  October  18,  191 1, 
for  the  third  time.  Her  first  entry  was  August  10,  1906.  At  that  time 
she  stated  that  she  had  had  dull  constant  pain  in  the  epigastrium  for  a 
year,  not  affected  by  food  and  not  literally  constant,  and  also  a  similar 
pain  low  down  in  the  back,  not  affected  by  menstruation  or  by  pos- 
ture. For  a  week  she  has  had  six  to  ten  watery  movements  a  day, 
without  blood  or  tenesmus.  Yesterday  the  pain  in  her  back  became 
very  severe,  and  was  compared,  by  her,  to  the  pains  of  childbirth. 
Morphin  was  given  subcutaneously.  Since  yesterday  there  has  been 
no  movement  of  the  bowels. 

Physical  examination  showed  normal  pupils  and  gums,  normal 
chest  and  abdomen,  normal  reflexes.  No  tenderness  along  the  spine 
or  over  the  sacro-iliac  joints.  Hip  movements  and  back  movements 
free  and  painless.  Uterus  was  slightly  antiflexed,  but  freely  movable 
and  of  normal  size.  There  was  tenderness  and  thickening  in  the 
region  of  the  left  broad  ligament.  Blood  and  urine  negative;  no  fever. 
Patient  seemed  so  slightly  sick  that  she  was  allowed  to  go  home  in  four 
days. 

Her  next  entry  was  April  18,  191 1,  when  she  said  that  she  had 
felt  pretty  well  until  a  year  previously,  when  she  began  to  have  an  in- 
termittent blood-tinged  vaginal  discharge,  lasting  during  June,  July, 
and  August,  1910,  and  accompanied  by  epigastric  pain.  The  latter 
has  persisted  ever  since.  Catamenia  began  April  17th,  a  week  before 
time.     Previously  to  that  time  it  had  not  been  abnormal. 

Three  months  ago  she  began  to  notice  a  sense  of  pressure  in  the 
epigastrium,  producing  eructations  of  gas  and  regurgitations  of  fluid 
after  meals.  Soon  after  that  she  noticed  a  pain  in  the  small  of  the 
back,  especially  when  lying  down,  and  subsequently  frequent  and 
scanty  though  not  painful  urination,  occurring  by  night  two  or  three 
times  and  more  often  in  the  daytime.  Two  weeks  ago  she  became 
conscious  of  a  mass  in  her  abdomen  which  feels  to  her  different  from 
the  enlargement  present  when  she  has  been  pregnant. 


342  DIFFERENTIAL   DIAGNOSIS 

Physical  examination  showed  a  mass  the  size  of  a  very  large  grape- 
fruit, extending  from  the  pelvis  to  a  point  2  inches  above  the  navel, 
broader  below  than  above,  and  extending  into  the  right  lower  quadrant 
farther  than  to  the  left.  It  was  freely  movable  from  side  to  side,  felt 
firm  and  not  fluctuant,  but  also  not  nodular.  Bimanually  the  uterus 
was  felt  in  front  of  and  below  the  tumor  mass,  with  which  it  seemed 
only  slightly  connected.  Pressure  upon  the  tumor  was  not  trans- 
mitted to  the  cervix,  but  pressure  upon  the  fundus  uteri  w^as  trans- 
mitted to  the  cervix.  April  2 2d  the  abdomen  was  opened  and  a 
single  solid  fibroma  of  the  right  ovary,  the  size  of  a  grape-fruit  and 
weighing  2000  grams,  was  removed.  Microscopically,  it  consisted  of 
edematous  fibrous  tissue,  with  occasional  small  cysts  in  the  midst  of  it. 
The  appendix  was  normal,  but  was  removed  on  general  principles. 
The  uterus  was  suspended  from  the  abdominal  wall. 

After  operation  the  patient  did  very  well,  and  was  discharged  May 
8th.  October  i8th,  of  the  same  year,  she  entered  once  more,  and  this 
time  it  was  learned  she  had  been  treated  in  the  Out-patient  Depart- 
ment since  October,  1904,  complaining  chiefly  of  pain  in  the  back  and 
constipation.  A  diagnosis  of  chronic  bronchitis  and  also  of  obesity  was 
made  at  that  time. 

After  leaving  the  hospital  in  June,  191 1,  she  remained  well  for 
about  three  weeks  and  weighed  140  pounds.  Then  she  began  to 
vomit  more  and  more  frequently,  and  went  to  the  Baptist  Hospital 
about  July  ist,  where  Dr.  M.  H.  Richardson  removed  a  large  left 
ovarian  cyst.  She  stayed  in  the  hospital  until  August  ist  and  vomited 
occasionally  throughout  this  period.  Since  discharge  she  has  vomited 
once  or  twice  every  day,  usually  after  meals  in  the  latter  part  of  the 
day,  but  she  sometimes  is  awakened  in  the  night  by  vomiting.  She 
has  ejected  large  amounts — a  gallon,  she  says — at  one  time,  always 
green  and  slimy,  but  without  blood.  Vomiting  bears  no  relation 
to  the  kind  of  food  taken.  She  has  no  severe  pain  and  no  jaundice, 
but  some  irregular  cramp-like  discomfort  in  the  lower  abdomen.  Her 
appetite  is  very  poor  and  she  says  she  has  lost  56  pounds.  Her  pres- 
ent weight,  without  clothes,  is  102  pounds.  At  the  Baptist  she 
weighed  134  pounds. 

Physical  examination  showed  moderate  emaciation,  marked 
tympany  in  the  epigastrium,  a  sense  of  resistance  in  the  right  lower 
quadrant,  and  a  sausage-shaped,  probably  fecal,  tumor  in  that  region. 
The  firm  sharp  edge  of  the  Hver  was  felt  at  the  costal  margin,  and  an 
irregular,  rounded,  firm,  insensitive  mass  was  also  felt  across  the  epi- 
gastrium, under  the  costal  margin.     This  mass  descended  wdth  respira- 


DYSPEPSIA 


343 


tion,  but  the  examiner  was  in  doubt  whether  it  was  continuous  with 
the  liver,  and  surmised  that  it  might  be  of  fecal  origin.  Except  as 
above,  external  examination  was  negative.  In  the  fasting  stomach 
a  large  amount  of  dark-brown  fluid  was  present,  probably  200  c.c.  or 
more.  Microscopically,  it  contained  many  sarcinai,  yeast  cells,  and 
epithelial  cells.  The  reaction  to  HCl  was  strong;  that  to  guaiac,  nega- 
tive. A  test-meal  was  vomited  at  the  end  of  fifteen  minues.  Second 
test-meal,  removed  at  the  end  of  an  hour,  showed  free  HCl  0.039  per 
cent.;  total  acidity,  0.135  per  cent.  No  guaiac.  The  capacity  of  the 
stomach  was  1560  c.c;  it  was  almost  impossible  to  wash  the  organ 


Fig.  122. — Gastric  outlines  in  Case  138. 

clean.  On  inflation  the  outline  was  as  in  Fig.  122.  The  mass  de- 
scribed in  the  epigastrium  disappeared  after  the  first  examination 
and  was  not  found  again.  Vaginal  examination  was  negative,  like- 
wise the  blood  and  urine.  Systolic  blood-pressure  105 ;  no  fever.  No 
guaiac  reaction  in  the  stools  on  three  tests.  October  2 2d  peristalsis 
was  seen  in  the  region  of  the  stomach,  especially  in  attacks  of  pain 
and  distress.  She  vomited  large  amounts  of  partially  digested  food 
each  evening,  fifteen  minutes  to  one  hour  after  supper. 

Bismuth  :r-ray  examination  showed  a  typical  picture  of  dilated 
stomach,  with  practically  complete  obstructions  at  the  pylorus  and 


344  DIFFERENTIAL   DIAGNOSIS 

absence  of  peristalsis.  When  standing  up  the  patient's  stomach  was 
low  and  far  to  the  right.  The  cause  of  this  obstruction  was  not  clear, 
but  the  record  states  that  ptosis  and  adhesions  were  considered  the 
most  probable  cause. 

Discussion. — Summing  up  this  rather  prolonged  case,  one  may  say 
that  a  woman  of  twenty-nine,  complaining  of  a  year's  dyspepsia 
and  of  a  recent  diarrhea,  with  very  severe  lumbar  pain,  is  first  treated 
in  1906  for  a  few  days,  and  recovers  so  speedily  that  no  definite  diag- 
nosis is  possible. 

Five  years  later  she  notices  intermittent  metrorrhagia  and  a 
return  of  the  dyspepsia,  which  in  the  meantime  has  been  in  abeyance, 
although  she  has  had  some  constipation  and  lumbar  pain  and  been 
treated  for  obesity.  She  is  operated  on  in  1911  for  fibroid  of  the  right 
ovary  and  soon  after  undergoes  a  second  operation  for  a  cyst  of  the 
left  ovary.  After  this  second  operation  she  becomes  rapidly  emaci- 
ated, losing  apparently  56  pounds  within  six  months.  At  the  end  of 
that  time  a  mass  is  found  in  the  epigastrium,  associated  with  gastric 
stasis,  visible  peristalsis,  and  :r-ray  evidence  of  pyloric  obstruction. 
All  this  evidence,  despite  the  fact  that  the  epigastric  mass  soon  dis- 
appeared, would  lead  us  to  conjecture  that  the  patient  now  has 
gastric  cancer.  Whether  or  not  this  growth  has  any  connection  with 
her  previous  ovarian  tumors  I  have  no  means  of  judging. 

Outcome. — October  24th  she  was  operated  upon  the  third  time, 
and  a  hard  tumor  found  at  the  pylorus,  extending  down  upon  the 
duodenum  about  i  inch  and  also  in  scattering  areas  over  the  anterior 
surface  of  the  stomach.  Hard  glands  were  found  along  the  lesser 
curvature  as  high  as  the  pyloric  vessels  and  behind  the  stomach. 
The  Uver  was  apparently  not  diseased.  Posterior  gastro-enterostomy 
was  done,  and  she  was  allowed  to  go  home  November  14th,  after  hav- 
ing an  uneventful  convalescence. 

Remarks. — The  case  is  worth  remembering  as  a  proof  that  gastric 
cancer  may  occur  at  twenty-nine. 

Case  139 

A  housewife  of  thirty-six  entered  the  hospital  November  16,  191 1. 
For  the  past  two  months  she  has  had  indigestion,  characterized  by  a 
heavy  ache  and  distressed  feeling  with  a  sense  of  pressure  in  the  epi- 
gastrium, one  to  three  hours  after  meals.  Never  any  sharp  pain. 
Distress  lasts  one  to  two  hours,  and  is  relieved  by  lying  down,  but  not 
by  medication.  Occasionally  vomits  in  these  attacks,  vomitus  being 
sour  and  containing  food  eaten  the  same  day.      At  first  she  was  re- 


DYSPEPSIA  345 

lieved  by  vomiting,  but  at  present  is  not.  Bowels  have  always  been 
constipated,  but  are  specially  so  of  late.  She  has  had  no  jaundice, 
no  headache,  or  edema.  She  has  gradually  eliminated  everything 
from  her  diet  except  milk  and  lime-water.  A  year  ago  her  weight 
was  125  pounds;  now,  100  pounds. 

Physical  examination  shows  poor  nutrition,  negative  chest. 
SystoHc  blood-pressure,  no;  abdomen  rigid,  tympanic,  not  tender. 
Reflexes  normal.  Before  breakfast  stomach  contained  about  20  c.c. 
of  brownish  turbid  fluid,  with  a  slight  reaction  to  guaiac,  and  0.04 
per  cent.  HCl,  but  no  evidence  of  food.  After  a  test-meal  the  con- 
tents showed  HCl  0.05  per  cent.     The  blood  and  urine  were  normal. 

Discussion. — Here  we  have  the  familiar  picture  of  a  person  who, 
with  the  best  intentions,  has  been  starving  herself  to  death  by  gradu- 
ally eliminating  from  her  diet  one  food  after  another  which  seem  to  her 
the  cause  of  her  discomforts. 

The  chief  point  of  interest  in  the  case  is  that  merely  by  starving 
herself  she  has  brought  her  dyspepsia  to  such  a  point  that  it  is  now 
associated  with  gastric  stasis,  doubtless  of  the  atonic  type.  Such  a 
stasis  need  cause  no  apprehension,  and  should  never  be  considered  a 
ground  for  operative  interference. 

A  great  many  such  cases  are  allowed  to  run  on  into  chronic  in- 
validism because  the  medical  attendant  has  not  the  courage  or  the 
personal  force  to  compel  his  patient  to  eat  despite  her  own  certainty 
that  she  cannot  do  so,  and  despite  the  very  real  discomforts  which 
follow  all  attempts  to  take  the  foods  which  have  previously  troubled 
her.  To  such  patients  I  frequently  quote  a  saying  of  a  lady  whose 
force  of  character  should  be  more  widely  admired  and  emulated,  "I 
am  not  going  to  be  bullied  by  my  stomach.  When  a  thing  disagrees 
with  me,  I  eat  it  again." 

Outcome. — She  remained  in  the  hospital  until  December  4th,  and 
it  became  evident  that  she  was  thoroughly  tired  out.  She  steadily 
improved  under  rest  and  an  occasional  dose  of  sodium  bicarbonate 
and  cascara,  with  mild  tonic  baths.  Stools  always  negative  to  guaiac. 
She  gained  4  pounds  in  seventeen  days. 

Remarks. — Genuine  fatigue  (which  must  be  clearly  distinguished 
from  the  nervous  sensations  of  fatigue  often  seen  in  persons  who 
have  undergone  no  physical  or  mental  strain  and  have  done  no  phys- 
ical or  mental  work  for  many  months)  is  not  infrequently  a  source  of 
very  persistent  gastric  and  cardiac  weakness.  Prolonged  rest  of 
mind  and  body  will  accomplish,  in  such  cases,  the  beneficial  results 
for  which  we  look  in  vain  in  neurotic  cases  subjected  to  a  rest  cure. 


346  DIFFERENTIAL  DIAGNOSIS 

Case  140 

A  maid  of  forty-eight  entered  the  hospital  November  25,  191 1. 
Family  history  negative.  Five  years  ago  she  was  taken  with  sudden 
severe  pain  in  the  epigastrium,  coming  immediately  after  a  luncheon 
and  lasting  three  or  four  hours.  It  did  not  radiate  and  was  finally 
relieved  by  powders,  the  nature  of  which  she  does  not  know.  In  this 
attack  she  vomited  food  just  eaten,  but  no  blood. 

Eight  months  ago  she  had  an  exactly  similar  attack  every  day 
for  a  week,  and  in  this  attack  she  was  jaundiced.  Pain  usually  re- 
lieved by  hot  drinks  and  by  "something  injected  into  her  arm." 
After  this  she  was  free  from  trouble  until  her  present  attack. 

For  the  last  month  she  has  had  almost  daily  attacks  of  indigestion, 
characterized  by  gastric  distress  and  a  gnawing  sensation  immedi- 
ately after  meals,  lasting  one-half  to  one  hour  and  not  amounting  to 
actual  pain.  Twice  she  has  vomited  sour  material.  There  has  been 
no  jaundice.  Four  days  ago  she  had  a  severe  attack  of  pain  in  the 
epigastrium  immediately  after  lunch.  The  pain  lasted  until  five 
o'clock  the  next  morning  and  was  very  severe.  She  took  no  medicine 
for  it  and  vomited  repeatedly. 

Two  days  ago  she  was  comfortable,  but  yesterday  had  moderately 
severe  pain,  coming  on  just  after  she  had  taken  her  soup  for  dinner, 
lasting  six  hours,  and  relieved  by  "mineral  water."  No  vomiting  this 
time,  but  the  patient  felt  feverish.  For  the  last  four  days  she  has 
eaten  nothing  but  malted  milk,  oatmeal  gruel,  and  cocoa.  Through- 
out her  last  attack  her  bowels  were  very  contipated  and  her  urine 
dark.  Her  best  weight,  eight  months  ago,  162  pounds;  now,  150 
pounds. 

For  four  years  she  has  noticed  a  bunch  in  the  lower  abdomen. 
Never  painful  or  inconvenient  in  any  way.  It  has  remained  of 
the  same  size.  Her  menstruation  often  lasts  between  one  and  two 
weeks. 

Physical  examination  shows  a  slight  yellowish  tint  to  the  skin 
and  possibly  a  slight  yellowish  discoloration  of  the  sclerse.  The 
pupils  are  slightly  irregular  in  outline,  but  otherwise  normal.  The 
gums  normal.     Chest  negative. 

In  the  abdomen  an  uneven  nodular  tumor  is  felt  above  the  pubes, 
in  the  area  shown  in  Fig.  123.  It  is  not  tender,  but  extends  down  well 
into  the  pelvis,  where  it  seems  to  be  connected  with  the  uterus.  It 
can  also  be  felt  by  rectum.  Reflexes  and  other  features  of  physical 
examination  are  negative.     Blood-pressure,    115.     Urine  and  blood 


DYSPEPSIA 


347 


negative,  except  for  a  slight  polynuclear  leukocytosis.  No  fever 
during  ten  days'  observation. 

Discussion. — A  bunch  noticed  for  four  years  in  the  lower  ab- 
domen is  generally  a  fibroid  tumor  of  the  uterus  or  an  ovarian  cyst, 
but  we  have  no  good  reason  to  suppose  that  this  patient's  dyspepsia 
of  the  past  eight  months  has  necessarily  any  connection  with  the 
long-standing  hypogastric  mass. 

The  nature  of  the  present  dyspeptic  troubles  becomes  much 
clearer  when  the  jaundice  is  found  on  physical  examination.     This 


r 

7] 

^^^^^^^n 

1    Har^. 

■  ■mov  a.b\e 

^HV    /=£=^=^ 

^^^^^H' 

^^^HV     ^ — 

HII' 

^^^^^^^^^B 

1 

1 

Fig.  123. — Abdominal  mass  felt  in  Case  140. 


jaundice,  taken  in  connection  with  the  attacks  of  pain  described  in  the 
history  and  relieved  apparently  by  an  injection  of  morphin,  makes  us 
pretty  confident  that  we  are  dealing  with  an  obstruction  in  the  biliary 
tract.  Such  an  obstruction  is  most  often  due  to  gall-stones,  and  this 
may  be  assumed  to  be  the  case  in  this  patient,  although  cancer  and 
other  causes  of  obstruction  cannot  be  positively  excluded  without 
operation.  Such  an  operation  should  be  advised  without  quaUfication. 
Outcome. — December  6th  the  abdomen  was  opened.  No  stones 
found  in  the  gall-bladder  or  ducts.  There  were  firm  adhesions  from 
the  fundus  of  the  gall-bladder  along  the  whole  length  of  the  cystic 


348  DIFFERENTIAL   DIAGNOSIS 

and  common  ducts,  attaching  them  to  the  transverse  mesocolon. 
When  these  were  detached  it  appeared  that  they  had  constricted  the 
fundus  of  the  gall-bladder. 

A  large  fibroid  tumor  adherent  to  the  omentum  and  the  intestines 
was  seen,  but  not  disturbed.  The  patient  made  a  good  recovery  and 
went  home  December  23d.  November  3,  1912,  she  wrote,  "I  have 
gained  steadily  and  am  now  in  good  health." 

Remarks. — It  is  to  be  noticed  that  the  surgeon,  by  a  remarkable 
act  of  self-restraint,  abstained  from  removing  the  fibroid  tumor. 
Such  an  example  is  to  be  emulated. 

Case  141 

A  housewife  of  thirty-two  entered  the  hospital  December  14,  191 1, 
stating  that  since  the  first  week  in  October  she  had  been  treated  for 
"nervous  dyspepsia."  October  24th  she  ate  steamed  clams,  and  next 
day  was  seized  with  vomiting  and  diarrhea ;  also  had  three  convulsions 
within  twenty-four  hours,  each  lasting  three  or  four  minutes,  the 
patient  becoming  cyanotic  during  them,  but  recovering  consciousness 
immediately.  Her  diarrhea  soon  ceased  and  she  had  no  more  con- 
vulsions, but  for  the  next  week  the  vomiting  continued  and  was  so 
obstinate  that  she  was  put  on  rectal  feeding.  The  vomiting  always 
came  from  two  to  twenty  minutes  after  eating,  consisting  of  sour, 
watery  material  in  large  amounts.     Food  rarely  seen,  blood  never. 

For  the  next  week  following  that  just  described  she  retained  food 
by  mouth,  then  the  vomiting  recurred  and  has  continued  ever  since. 
There  is  constant  nausea  and  epigastric  distress,  but  no  pain.  All 
sorts  of  medicines  and  foods  have  been  given  without  relief,  although 
her  symptoms  can  be  temporarily  checked  by  suppositories  of  codein. 
She  has  lost  15  pounds  in  weight.     Her  appetite  is  always  good. 

Although  the  convulsions  above  described  are  something  entirely 
new  for  her,  she  remembers  having  had,  seven  years  ago,  a  ''dizzy 
spell,"  which  kept  her  in  bed  all  day,  and  was  accompanied  by  numb- 
ness of  the  tongue,  mouth,  and  left  arm.  The  dizziness  has  recurred 
twice  lately,  "but  since  the  doctor  took  blood  from  her  arm  there 
has  been  no  numbness  in  it." 

The  pupils  are  irregular,  the  left  larger  than  the  right.  Both 
react  well  to  distance,  but  not  to  light.  There  is  a  slight  general 
glandular  enlargement.  Chest  and  abdomen  negative.  Slight  left 
dorsal  scoliosis.  The  right  knee-jerk  was  present,  the  left  not  ob- 
tained; there  was  no  swaying  when  she  stood  with  the  eyes  closed 
and    the    feet    together.     Stomach-tube,    passed    before    breakfast, 


DYSPEPSIA  349 

showed  no  food  and  no  blood.  Capacity  of  the  organ,  looo  c.c. 
Contents  of  the  fasting  stomach  showed  free  HCl  0.31  per  cent. 
After  a  test-meal,  free  HCl  0.35  per  cent.;  total  acidity,  0.41  per  cent. 
No  reaction  to  guaiac.  Blood  and  urine  normal.  No  fever  in  two 
weeks'  observation,  during  which  time  she  gained  4  pounds.  The 
Wassermann  reaction  of  the  blood  was  negative;  in  the  spinal  fluid, 
December  19th,  strongly  positive.     The  fundus  oculi  was  normal. 

During  the  first  four  days  in  the  ward  she  continued  to  be  nau- 
seated, the  nausea  bearing  no  relation  to  food,  and  being  relieved  by 
vomiting  about  once  in  eight  hours.  Atropin,  y|o  grain,  three  times 
a  day  on  December  17th,  twice  daily  from  the  i8th  to  the  26th, 
seemed  to  control  the  vomiting  better  than  any  other  drug.  By  the 
23d  she  was  eating  well.  While  taking  atropin  she  had  night-sweats. 
Following  the  omission  of  this  drug  they  ceased. 

Discussion. — This  is  a  fairly  typical  case  of  gastric  manifestations 
in  tabes  dorsalis.  The  condition  of  the  pupils,  knee-jerks,  and  glands 
should  have  made  clear  the  nature  of  her  trouble,  especially  as  she 
had  previously  had  a  convulsion  and  some  symptoms  suggesting  a 
focal  brain  lesion.  The  positive  Wassermann  reaction  in  the  spinal 
fluid  put  the  case  beyond  any  doubt,  yet  I  have  known  patients  pre- 
senting symptoms  just  as  clearly  tabetic  as  those  just  described  who 
were,  nevertheless,  operated  upon  because  a  routine  examination  of  the 
nervous  system  has  not  yet  become  part  of  the  medical  technic  of  the 
average  surgeon.  Failure  to  recognize  tabes  dorsalis  is  excusable 
when  the  pupils  and  knee-jerks  are  normal,  but  not  in  a  case  like 
this. 

Outcome. — It  was  subsequently  learned  that  her  pupils  had  failed 
to  react  alike  at  any  time  in  the  last  eight  years.  That  one  year  ago 
she  had  sharp  stabbing  pains  in  her  knees,  lasting  a  few  days  and 
accompanied  by  marked  hyperesthesia.  She  has  been  married  for 
three  years,  has  had  no  children,  and  no  miscarriages.  January  i, 
191 2,  she  left  the  hospital  in  good  condition. 


CHAPTER  V 

HEMATEMESIS 

There  are  but  two  common  causes  of  hematemesis,  by  which  I 
mean  the  vomiting  of  pure  blood  in  considerable  quantity,  an  ounce 
or  more.  Those  causes  are  peptic  ulcer  and  cirrhosis  of  the  liver. 
When  an  alcoholic  vomits  blood,  it  is  often  impossible  to  decide 
whether  the  hematemesis  is  due  to  cirrhosis  or  to  congestion  of  the 
stomach  itself,  but  this  distinction  is  not  of  great  practical  importance. 

At  the  end  of  any  period  of  violent  retching,  however  produced, 
a  small  amount  of  blood  may  be  ejected  without  there  being  any 
organic  disease  responsible  for  it. 

A  third,  but  much  less  common,  cause  for  hematemesis  is  that 
vaguely  deiined  condition  known  as  splenic  anemia,  and  the  later 
sequel  of  the  same  malady  called  Banti^s  disease. 

Gastric  cancer  is  rarely  associated  with  the  vomiting  of  pure 
blood  in  considerable  amounts.  The  ulcerated  surface  of  the  cancer 
oozes  continually,  and  the  blood  thus  discharged  is  digested  into  a 
material  resembling  coffee-grounds.  This  may  be  ejected  when  the 
patient  vomits.  It  must  be  remembered,  however,  that  a  vomiting 
of  brownish  fluid  indistinguishable  from  that  of  gastric  cancer  is 
frequently  seen  after  surgical  operations  upon  the  abdomen.  It  has 
no  special  significance,  and,  although  it  occurs  in  general  and  in 
local  peritonitis,  it  is  not  at  all  peculiar  to  these  conditions. 

The  differential  diagnosis  of  the  causes  of  hematemesis  rests 
largely  upon  a  good  history  of  the  case.  Digestive  disturbances  of 
the  type  characteristic  of  ulcer  are  usually  distinguished  without 
much  difficulty  from  those  secondary  to  cirrhosis  of  the  liver.  In 
ulcer  the  physical  examination  is  usually  negative.  In  cirrhosis  we 
may  be  able  to  make  out  changes  in  the  liver  or  portal  stasis.  In 
splenic  anemia  the  spleen  is  usually  so  much  enlarged  that  anyone  who 
knows  enough  to  feel  for  it  will  recognize  it. 

Case  142 

A  plasterer  of  fifty-two  entered  the  hospital  June  27,  1904.     Ac- 
cording to  the  patient's  account  he  has  never  been  sick  until  within 
the  past  month,  when  he  began  to  have  dull,  steady  pain  in  the  epigas- 
350 


Hematemesis 

AFTER  VIOLENT  RETCHING  (FROM   ANY  CAUSE) 

PEPTIC  ULCER  ■■■■^^^^■■^^■■■^^■^■i^HHHi  261 

GASTRIC  CANCER  ^i^HHiB^Hi^^^H^i^Haii^HiiH  233 


CIRRHOSIS    OF    THE 
LIVER 


135 


UNKNOWN   CAUSE  ■■^■^i^lH  88 

SPLENIC  ANEMIA  ■■  22 

ALCOHOLIC  GASTRITIS    ■  8 


351 


352 


DIFFERENTIAL  DIAGNOSIS 


triiim,  not  increased  by  food  and  not  relieved  by  pressure.  Yesterday, 
while  in  the  elevated  train,  he  suddenly  vomited  much  dark-brown 
fluid.  This  was  repeated  several  hours  later,  and  this  time  the 
vomitus  contained  blood.     Since  then  he  has  felt  weak. 

During  the  past  month  he  has  lost  some  weight,  but  previous  to 
that  time  he  positively  denies  any  stomach  trouble.  His  appetite  is 
fair,  bowels  regular,  sleeps  good.     He  takes  no  alcohol. 

Physical  examination  shows  good  nutrition.  The  heart's  apex, 
of  a  heaving  quahty,  is  felt  in  the  sixth  space,  i^  inches  outside  the 
nipple.  There  was  no  increase  of  dulness  to  the  right.  Its  action  is 
markedly  irregular.  There  is  a  presystolic  thrill  and  a  presystolic 
murmur  at  the  apex,  transmitted  to  the  axilla  and  back.  At  the 
third  left  costal  cartilage  there  is  a  blowing  systolic  murmur.  The 
pulmonic  second  sound  is  greater  than  the  aortic  second.  The  right 
pulse  is  larger  than  the  left,  artery  walls  easily  palpable.  The  ab- 
domen is  somewhat  retracted  and  rigid,  but  shows  no  masses  or  ten- 
derness. Visceral  examination  is  otherwise  negative,  as  is  the  urine. 
The  blood  shows  red  cells,  1,728,000;  white,  11,600;  hemoglobin,  55 
per  cent. 

On  the  morning  of  the  28th  he  had  a  copious  gastric  hemorrhage, 
about  a  quart  in  ail.  At  10  a.  m.  6  ounces  more  were  ejected.  The 
blood-smear  showed  marked  achromia,  considerable  deformities,  some 
stippling,  no  blasts;  differential  count  negative. 

Discussion. — When  a  man  of  fifty-two  vomits  blood  without  any 
previous  gastric  symptoms,  cirrhosis  of  the  liver  is  the  most  probable 
cause.  In  this  case  there  have  been  gastric  symptoms,  although 
moderate  in  degree  and  lasting  only  a  month.  There  has  been  no 
alcoholic  history,  no  splenic  enlargement,  or  previous  anemia.  The 
amount  of  blood  vomited  is  large  and  the  resulting  anemia  extreme. 
With  this  picture,  peptic  ulcer  of  the  stomach  or  duodenum  is  the  most 
probable  diagnosis,  however  little  the  physical  examination  may  show. 
Gastric  cancer  may  cause  a  similar  hemorrhage,  but  this  is  very  rare. 

We  have  also  the  evidence  of  mitral  stenosis,  with  a  markedly 
enlarged  heart,  such  as  many  clinicians  are  in  the  habit  of  supposing 
to  be  incompatible  with  mitral  stenosis.  I  see,  however,  no  consider- 
able reason  to  doubt  that  the  mitral  valve  is  contracted.  Has  this 
any  relation  to  the  vomiting  of  blood?  I  see  no  reason  to  believe  so. 
Blood  coming  from  the  lungs,  as  a  result  of  pulmonary  infarct  in 
mitral  stenosis,  may  be  swallowed  and  then  vomited,  but  not  in  any 
such  amount  as  is  here  described  and  not  without  previous  symp- 
toms of  pulmonary  congestion. 


HEMATEMESIS  353 

The  case  illustrates  one  of  the  extraordinary  varieties  in  the  clinical 
picture  of  peptic  ulcer,  a  disease  which  may  produce  symptoms  lasting 
over  twenty  years  or  may  produce  no  symptoms  at  all,  and  may  be 
found  at  autopsy  in  a  patient  who  dies  of  something  else.  Perfora- 
tion and  general  peritonitis  may  be  the  first  hint  that  any  such  disease 
exists,  or,  as  in  the  present  case,  after  a  brief  and  mild  dyspepsia  we 
may  have  a  large  gastric  hemorrhage. 

I  have  no  idea  why  the  right  pulse  is  larger  than  the  left  in  this 
case.  Such  difference  is  of  significance  only  when  it  is  linked  up  with 
other  signs  pointing  to  an  aortic  aneurysm.  As  an  isolated  fact,  it  is 
fairly  common  in  health  and  in  a  variety  of  diseases.  So  far  as  I 
know,  it  has  no  significance. 

Outcome. — About  4  p.  m.  on  the  28th  the  pulse  became  very  poor, 
and  during  that  night  he  vomited  8  ounces  more  of  blood  and  died  on 
the  29th.  Autopsy  showed  ulcer  of  the  stomach;  erosion  of  a  branch 
of  a  gastric  artery;  mitral  stenosis;  arteriosclerosis;  hypertrophy  and 
dilatation  of  the  heart;  obsolete  tuberculosis  of  the  left  lung  and  of  a 
bronchial  lymph-gland. 

Case  143 

A  housewife  of  thirty-five  entered  the  hospital  March  24,  1908. 
The  patient  has  lost  one  brother  by  phthisis,  otherwise  her  family 
history  is  excellent.  Three  years  ago  she  was  in  St.  Elizabeth's 
Hospital  for  ten  weeks  with  stomach  trouble.  While  there  the  uterus 
was  cureted.  Five  years  ago  she  weighed  144  pounds;  now,  no 
pounds. 

In  the  intervening  five  years  she  has  had  attacks  of  vomiting  at 
intervals  not  exceeding  two  weeks  at  a  time.  At  first  they' came  before 
the  menstrual  period;  later,  at  other  times.  The  vomitus  contains 
food  of  the  previous  meals  and  some  watery  material.  Pain  in  the 
epigastrium  comes  soon  after  eating.  It  is  relieved  by  vomiting. 
Three  years  ago  she  vomited  two  cupfuls  of  dark  blood.  This  was  at 
the  time  she  was  in  St.  Elizabeth's  Hospital.  She  was  put  on  a  milk 
diet.  In  November,  1907,  five  months  ago,  she  again  vomited 
blood,  and  this  time  had  black  stools  and  was  in  bed  a  week.  She 
has  never  vomited  blood  again  so  far  as  she  knows,  but  has  continued 
to  have  epigastric  pain  and  tenderness  after  eating.  The  last  attack 
of  vomiting  was  on  March  15th.  Appetite  is  poor,  bowels  costive; 
no  other  symptoms. 

Physical  examination  showed  fair  nutrition,  slight  pallor,  normal 
pupils,  glands,  and  reflexes.     The  chest  was  negative,  save  for  a  soft. 

Vol.  11—23 


354  DIFFERENTIAL  DIAGNOSIS 

systolic  murmur,  limited  to  the  region  of  the  cardiac  apex.  The 
abdomen  was  negative.  Examination  of  the  stomach  with  a  tube 
showed  no  evidence  of  enlargement;  negative  guaiac  test,  free  HCl, 
0.14  per  cent.;  total  acidity,  0.25  per  cent.  The  stools  were  negative 
to  guaiac  at  entrance.  Upon  a  diet  of  eggs  and  milk  the  patient  did 
fairly  well.  The  gastric  distress  markedly  diminished  and  there 
was  no  more  blood,  either  by  stomach  or  rectum.  May  2d  she  left 
the  hospital  to  continue  her  treatment  at  home. 

August  3,  1908,  she  entered  the  second  time,  stating  that  two 
weeks  after  she  left  the  hospital  she  had  another  attack  of  vomiting, 
and  then  was  quite  well  until  July  17th,  when  she  had  another  attack 
at  the  time  of  her  menstruation,  lasting  three  days.  The  vomitus 
was  dark  brown  in  color,  accompanied  by  epigastric  pain. 

This  time  the  patient  was  well  nourished,  and  showed  no  abnor- 
mality except  for  the  red  cells,  which  were  now  3,050,000;  white, 
13,4000;  hemoglobin,  45  percent.  Differential  count  showed  82  per 
cent,  polynuclear  cells,  and  in  the  stained  smear  there  were  two  nor- 
moblasts, some  deformities,  and  achromia  of  the  red  cells.  The  urine 
was  negative.  The  entrance  diagnosis  at  this  time  was  gastric  ulcer, 
but  the  morning  after  entrance  a  small,  hard  mass  was  felt  in  the 
epigastrium,  just  to  the  left  of  the  median  line.  There  was  no  food 
residue  in  the  fasting  stomach.  On  inflation  its  outlines  were  normal 
and  the  mass  could  not  be  felt.  Guaiac  test  was  positive  in  the  con- 
tents after  a  test-meal;  HCl  0.84  per  cent.  Stools  negative  to 
guaiac. 

Discussion. — The  patient  has  had  vomiting  spells,  lasting  two 
weeks  or  less,  for  the  past  five  years  and  has  lost  34  pounds  in  that 
period.  The  first  hematemesis  was  three  years  ago;  the  second,  five 
months  ago.  Presumably  the  association  with  the  menstrual  period, 
at  the  time  of  the  first  hematemesis,  was  a  coincidence.  Unlike  most 
patients  with  gastric  ulcer,  she  had  a  poor  appetite.  Nevertheless, 
the  total  impressions  of  her  illness  during  her  first  stay  in  the  hospital 
is  that  of  a  peptic  ulcer.  She  improved  as  such  cases  do,  and  the 
condition  of  her  stomach  contents  was  fairly  typical  of  that  disease, 
although  the  guaiac  test  was  negative. 

When  she  entered  the  hospital  the  second  time,  with  a  well-marked 
anemia  and  a  palpable  mass  in  the  epigastrium,  the  question  at  once 
arose,  Is  this  lump  a  perigastric  exudate  representing  a  local  peritoni- 
tis about  the  site  of  an  ulcer?  Such  an  exudate  may  feel  as  hard  as 
any  cancer.  Against  ulcer,  however,  is  the  fact  of  anemia  without 
any  recurrence  of  the  hematemesis.     It  is  quite  possible,  nevertheless, 


HEMATEMESIS 


355 


that  there  may  have  been  bleeding  without  the  patient's  knowledge 
and  without  vomiting.  On  the  whole,  the  evidence  for  ulcer  and  that 
for  cancer  is  very  evenly  balanced,  and  it  is  difficult  to  make  a  choice. 
The  rarity  of  perigastric  exudates  producing  epigastric  tumor  inclines 
me,  on  the  whole,  toward  the  diagnosis  of  cancer. 

Outcome. — On  the  14th  of  August  the  hemoglobin  had  risen  to 
50  per  cent,  and  the  abdomen  was  opened.  The  posterior  wall  of  the 
stomach  contained  a  firm,  hard  mass,  the  size  of  an  almond,  with 


Fig.  124. — Keloid-like  masses  in  old  linea  albicantes  (Case  143). 


radiating  branches  extending  over  the  whole  posterior  side  of  the 
stomach,  especially  at  the  pyloric  end.  The  omentum  was  filled  with 
small,  hard  nodules.  An  anterior  gastro-enterostomy  was  done, 
after  which  the  patient  did  well  and  left  the  hospital  on  the  17th  of 
September.  On  the  i8th  of  January,  1909,  she  came  back  again, 
stating  that  since  the  first  of  October,  1908,  she  has  had  a  sense  of 
pressure  on  the  bladder  with  frequent  micturition.  This  was  soon 
followed  by  enlargement  of  the  abdomen,  which  has  gone  on  up  to  the 


356  DIFFERENTIAL   DIAGNOSIS 

present  time.  The  stomach,  on  the  whole,  has  done  very  well,  except 
for  occasional  attacks  of  nausea  or  vomiting.  Hemoglobin  at  this 
time  was  75  per  cent.  Urine  negative.  The  lineae  albican tes  below 
the  navel  have  developed  into  branching  ridges  which  suggest  keloid 
(Fig..  124). 

The  lower  half  of  the  abdomen  is  occupied  by  an  irregular,  hard, 
insensitive  mass,  the  size  of  a  football,  reaching  as  high  as  the  navel 
and  extending  into  the  iliac  fossae,  with  slight  depression  in  the  median 
line.  There  are  no  sounds  over  it  on  auscultation.  No  blueness 
of  the  vulva.  Vaginal  examination  shows  just  behind  the  pubes  a 
mass,  which  is  interpreted  as  the  fundus  of  the  uterus.  Pressure 
over  the  abdominal  tumor  causes  movement  on  the  part  of  the  cervix. 
On  the  25th  the  abdomen  was  opened  again  and  found  to  contain 
several  quarts  of  fluid  and  two  tumors,  each  the  size  of  a  large  grape- 
fruit, nodular,  grayish-white  in  color,  and  apparently  arising  from 
the  ovaries.  These  were  removed  and  showed  the  microscopic  struc- 
ture of  fibroma,  with  small  cyst-like  cavities.  The  patient  left  the 
hospital  on  the  23d  of  February  in  good  condition,  but  died  at  the 
Vincent  Hospital  June  11,  1909.  After  May  20th  she  was  kept  under 
opiates. 

Remarks. — The  mass  felt  in  the  lower  abdomen  in  January,  1909, 
was  at  first  interpreted  as  a  metastasis  from  the  stomach.  Later 
the  question  of  pregnancy  arose,  as  the  tumor  seemed  obviously 
connected  with  the  cervix  uteri.  The  final  interpretation  given  to 
this  mass  was  that  it  represented  a  uterine  fibroid.  No  one  suspected 
ovarian  tumor. 

The  condition  of  the  abdominal  wall  is  fairly  well  suggested  in  the 
accompanying  photograph  (Fig.  124).  Those  curious  scars,  ordinarily 
known  as  line<z  albicantes,  had,  in  this  case,  become  hypertrophied  like 
keloid  and  then  edematous  and  at  times  inflamed.  They  stood  up 
from  the  surrounding  tissues  |  inch  or  more,  and  were  as  thick  as  a 
finger. 

Familiar  as  are  linecB  albicantes  upon  the  abdomen  of  women 
who  have  borne  children,  I  do  not  think  their  nature  is  yet  well 
imderstood.  One  sees  them  not  only  in  this  situation,  but  over  the 
deltoids,  along  the  lower  ribs  in  the  axilla,%  and  in  many  other  parts  of 
the  body,  under  conditions  which  makes  their  occurrence  distinctly 
mysterious.  They  seem  to  have  something  to  do  with  loss  of  weight, 
yet  in  the  abdomen  we  have  usually  explained  them  as  a  result  of 
stretching  of  the  skin  and  spKtting  of  its  superficial  layers.  This 
explanation,  however,  will  not  hold,  when  one  sees  them  about  the 


HEMATEMESIS  357 

shoulders  and  back  during  the  convalescence  of  a  case  of  scarlet 
fever  or  after  other  infectious  diseases.  Under  such  conditions  there 
can  have  been  no  stretching  of  the  skin,  as  neither  emaciation,  obesity, 
nor  other  cause  for  pressure  and  stretching  has  been  present. 

It  is  not  always  realized  that  these  hnes,  which  in  their  later 
stages  are  white,  are  in  their  earher  stages  bright  red  and  suggest 
inflammation  or,  at  least,  hyperemia.  As  far  as  I  know,  they  have  no 
useful  lessons  to  teach  us,  so  far  as  diagnosis  is  concerned,  but  it  is 
important  to  be  familiar  with  the  variety  of  appearance  which  they 
may  present,  otherwise  one  may  be  unduly  puzzled  when  discovering 
them  in  a  case  which  seems  in  other  respects  clear. 

Case  144 

An  unoccupied  man  of  thirty-six  entered  the  hospital  January  29, 
1909,  with  a  diagnosis  of  "gastric  ulcer."  One  month  ago  he  began  to 
vomit  immediately  after  eating.  Ice-cream  and  raw  oysters  were  the 
only  foods  that  he  could  take.  For  the  past  two  weeks  he  has  vomited 
blood,  dark  and  clotted,  as  much  as  a  cupful  at  a  time,  both  after  eat- 
ing and  between  meals.  The  blood  is  sometimes  clear,  sometimes 
mixed  with  food. 

Physical  examination  showed  loss  of  weight,  marked  pallor,  normal 
pupils,  glands,  and  reflexes.  Chest  negative,  save  for  a  soft  systoHc 
souffle  at  the  apex,  not  transmitted.  In  the  epigastrium  and  right  upper 
quadrant  there  was  tenderness  and  muscular  spasm ;  otherwise  physical 
examination  was  negative.  Red  cells,  800,000;  white  cells,  21,000; 
hemoglobin,  20  per  cent.  Differential  count  normal.  The  stained 
smear  showed  marked  achromia,  slight  deformities  of  the  cells;  other- 
wise normal.  Urine  normal.  He  was  given  at  entrance  horse  serum, 
20  c.c,  subcutaneously.  By  the  5th  of  February  the  red  cells  had 
risen  to  2,400,000,  the  hemoglobin  to  40  per  cent.  On  gastric  ulcer 
diet  he  had  had  no  bleeding. 

By  the  loth  of  February  he  could  eat  a  full  diet  without  any 
trouble,  and  the  diagnosis  of  gastric  ulcer  would  undoubtedly  have 
been  made  but  for  the  following  additional  facts,  which  were  added  to 
the  history  at  this  time.  He  first  entered  the  hospital  September  21, 
1899,  when  it  was  learned  that  there  was  a  good  deal  of  mental  defi- 
ciency on  the  mother's  side  of  the  house.  Some  of  her  family  were 
''queer  and  silly."  The  boy  had  convulsions  for  five  days  after  his 
birth.  He  was  born  jaundiced.  This  lasted  two  weeks.  He  was, 
nevertheless,  a  healthy  baby,  and  had  no  more  convulsions  until 
he  was  five.     Ever  since  then  he  has  had  them  frequently,  sometimes 


358 


DIFFERENTIAL   DIAGNOSIS 


twice  a  week,  sometimes  skipping  several  weeks.  They  are  preceded 
by  a  typical  aura  and  cry.  The  head  always  turns  to  the  right,  and 
he  bites  his  tongue  unless  his  jaws  are  kept  separated.  After  two  or 
three  minutes  he  awakes  from  his  coma  with  severe  headache.  Under 
treatment  he  once  went  two  years  without  convulsions,  but  when 
medicine  was  stopped  the  convulsions  returned.  He  often  has  spells 
of  what  he  calls  "smothering,"  when  his  lips  get  blue  and  he  cannot 
speak  for  a  minute  or  two. 

He  has  always  been  subject  to  bleeding  on  sHght  provocation  since 
he  was  six  years  old,  when  he  cut  his  face,  and  the  bleeding  lasted  five 
weeks;  it  was  finally  stopped  by  cautery.  In  1895  two  teeth  were 
pulled  to  stop  his  biting  his  tongue  and  the  bleeding  lasted  four 
weeks.  Four  years  ago  he  had  "some  bones  taken  out  of  his  chest," 
and  he  raised  a  great  deal  of  blood  at  that  time.  On  one  occasion  a 
puncture  of  the  ear,  made  for  blood  examination,  bled  for  three  days. 

Eight  years  ago,  July  30, 1901 , 
he  was  recommended  to  the  sur- 
gical wards  with  a  question  of 
renal  stone  or  tuberculosis,  be- 
cause for  a  week  his  urine  had 
contained  much  blood.  He  had 
also  had  much  pain  and  burning 
sensation  in  the  back  and  in  the 
genitals;  also  pain  in  the  peri- 
neum when  sitting  He  had  an 
epileptic  fit  in  the  ward,  and  was 
soon  discharged  to  the  medical 
service.  The  urine  then  con- 
tained a  large  amount  of  blood, 
but  was  not  otherwise  remark- 
able. 150  c.c'  of  2  per  cent, 
gelatin,  in  sterile  salt  solution, 
were  injected  on  the  3d  of  August 
and  followed  by  a  rise  of  tem- 
perature, as  shown  in  Fig.  125.  There  was  considerable  pain  and 
tenderness  at  the  site  of  injection,  which  was  repeated  on  the  6th 
and  on  the  loth.  On  the  5th  of  August  he  had  considerable  ab- 
dominal pain  and  passed  bloody  stools. 

He  had  several  convulsions  during  this  stay  in  the  ward,  but  his 
urine  became  free  from  blood  on  the  12th  of  August  and  remained  so. 
In  the  absence  of  any  other  special  symptoms  he  was  discharged  on 


Tu/i^   1101 

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Fia 


-Chart  of  Case  144. 


HEMATEMESIS  359 

the  2ist,  and  was  not  seen  again  until  his  entrance  ten  years  later 
in  1909,  as  described  above. 

The  patient  left  the  hospital  on  the  nth  of  January,  1909,  and 
re-entered  on  the  25  th  of  February,  stating  that  five  days  pre- 
viously hematemesis  recurred  and  has  been  frequent  ever  since. 
Two  days  ago,  after  a  violent  epileptic  attack,  he  complained  of 
occipital  headache,  with  coldness  and  chilliness  of  the  left  arm. 
He  has  slept  but  Kttle,  he  says,  for  some  weeks,  and  has  had 
much  heartburn.  At  entrance  he  was  very  restless,  asking  for  hot 
whisky  and  mother.  His  head  is  described  by  the  house  officer 
as  faun-like,  with  pointed  '       '         "   -'--^n    anW 

close  together.     No  history 
obtained. 

Physical  examination  wi 
cells,  1,056,000;  white,  920c 

cells,  79  per  cent.     The  red  ccua  oxx 

and  shape;  no  other  abnormality.  The  patient  continued  to  vomit 
blood  in  spite  of  morphin  and  horse  serum.  His  pulse  grew  steadily 
weaker,  and  he  died  on  the  26th  of  February,  without  any  other  symp- 
toms. 

Discussion. — We  had  no  doubt  of  the  diagnosis  of  peptic  ulcer 
when  we  made  our  earliest  record  of  this  patient's  case.  Later, 
when  we  learned  that  he  had  been  a  bleeder,  we  naturally  shifted  our 
diagnosis  and  considered  the  gastric  bleeding  as  part  of  the  hemo- 
philiac diathesis.  It  appeared  that  he  had  had  hemorrhage  from  the 
lungs,  bowel,  and  kidney,  as  well  as  subcutaneously. 

His  convulsions  were  attributed  to  epilepsy,  and  we  supposed  them 
to  be  without  any  connection  with  his  other  symptoms.  His  un- 
satisfactory inheritance  made  the  epilepsy  easily  explicable. 

Outcome. — Autopsy  showed  chronic  interstitial  hepatitis  with  focal 
necrosis;  hyperplasia  of  the  spleen;  fatty  degeneration  of  the  myo- 
cardium; chronic  pericarditis;  hypertrophy  and  dilatation  of  the 
heart;  obsolete  tuberculosis  of  a  bronchial  lymphatic  gland;  chronic 
pleuritis;  internal  hydrocephalus  of  the  left  cerebral  hemisphere,  with 
marked  atrophy  of  the  surrounding  convolutions. 

Remarks. — After  the  autopsy  we  were  not  quite  certain  how 
far  our  previous  diagnosis  of  hemophilia  was  a  mistake.  Gastric 
bleeding  in  a  patient  with  interstitial  hepatitis  is  naturally  attributable 
to  the  latter  disease.  Nevertheless,  this  patient  had  had  blood  in  his 
urine  and  from  other  sites  not  to  be  connected  with  any  disease  of 
the  liver.     Since  no  definite  point  of  hemorrhage  was  noted  in  the 


360  DIFFERENTIAL  DIAGNOSIS 

autopsy  record,  there  is  no  proof,  so  far  as  I  see,  that  his  cirrhosis  was 
the  cause  of  his  bleeding  from  the  stomach.  Such  connection,  how- 
ever, cannot  be  excluded. 

It  is  quite  possible  that  his  hepatitis  may  have  been  syphilitic, 
although  no  Wassermann  reaction  was  done. 

The  diagnosis  of  epilepsy  was  certainly  wrong,  as  one  can  only 
use  that  term  to  denote  cases  in  which  no  organic  lesions  exist.  As 
to  the  origin  of  his  hydrocephalus,   I  have  nothing  to  suggest. 

Case  145 

A  Hriifrrr^c-f  of  fifty-four  entered  the  hospital  January  20,  1910. 

'  't  i-.  ther  died  of  cancer  of  the  face  at  sixty-one;  otherwise 

ry  is  good,  and  he  has  always  been  well.     For  years 

fteen  glasses  "«f  beer  or  whisky  daily,  now  four  or  five 

On  this  diet  he  has  seemed  to  thrive. 

7  A.  M.,  after  a  coughing  spell,  he  began  to  raise 

blood,  at  first  in  2-ounce  quantities.     At  2  p.  m.  he  vomited  i  pint, 

at  6  p.  M.  I  pint  more,  and  soon  after  this  he  passed  two  dark  and 

tarry  stools.     At  3  a.  m.  to-day  he  vomited  ^  pint  more,  and  at  noon 

to-day  again  ^  pint  and  had  two  more  tarry  movements.     In  all,  he 

thinks  he  has  raised  i  quart  and  18  ounces. 

Physical  examination  shows  obesity,  pallor,  normal  pupils,  glands, 
and  reflexes.  The  heart's  apex  is  i  cm.  outside  the  nipple  line. 
Slight  systolic  murmur  along  the  left  sternal  border.  Systolic 
blood-pressure,  125.  The  right  pulse  is  greater  than  the  left,  both 
slightly  irregular.  The  liver  dulness  extends  from  the  sixth  rib, 
mammary  line,  to  a  point  6  cm.  below  the  ribs,  where  a  rounded  edge 
is  felt. 

Discussion. — Such  a  hemorrhage  occurring,  as  we  say,  out  of  a 
clear  sky,  in  an  alcoholic,  with  a  palpable  liver,  can  scarcely  be  at- 
tributed to  a  cause  other  than  interstitial  hepatitis.  We  have  no 
reason  to  be  surprised  that  the  patient  has  no  portal  stasis,  that  is, 
none  of  the  ordinary  evidences  of  that  condition.  Whether  the 
hemorrhage  is  due  to  passive  congestion  of  the  gastric  mucosa  or 
to  dilatation  of  the  peri-esophageal  plexus  of  veins,  we  cannot  say. 
The  latter  is  the  more  common. 

Outcome. — On  the  evening  of  the  2 2d  he  suddenly  became  de- 
lirious and  tried  to  get  out  of  bed,  complaining  of  feeling  queer. 
His  pulse  soon  became  slow,  weak,  respirations  labored,  and  the  pic- 
ture, save  for  the  pulse,  was  one  of  internal  hemorrhage.  In  two 
hours  he  died. 


HEMATEMESIS  36 1 

Remarks. — Such  a  hemorrhage  is  rarety  fatal.  As  a  rule,  the 
patient  lives  on  for  months,  often  for  many  years,  and  may  die  of 
some  other  disease. 

Case  146 

An  Irish  cook  of  twenty-two  entered  the  hospital  June  i8,  1910. 
The  patient  has  a  good  family  history  and  past  history,  but  has  al- 
ways had  much  pain  at  menstruation,  especially  during  the  last  year, 
when  the  period  has  been  accompanied  by  nausea  and  vomiting  for 
one  or  two  days.  Of  late  she  vomits  first  food,  then  bile,  and  finally 
dark  clots  of  blood  at  the  end  of  half  an  hour  of  steady  retching. 
She  is  much  exhausted  by  these  attacks  and  sweats  profusely.  Be- 
tween periods  she  has  no  symptoms,  and  can  eat  anything  without 
distress.  She  has  no  loss  of  weight,  good  appetite,  and  has  worked 
steadily. 

Physical  examination  was  wholly  negative,  including  the  blood, 
urine,  and  temperature.  Stools  were  negative  to  guaiac.  The  stomach- 
tube  showed  no  contents  in  the  fasting  stomach.  A  test-meal  was 
vomited  after  thirty-five  minutes,  the  vomitus  containing  no  free 
HCl  and  no  blood.     A  retroverted  uterus  was  replaced  under  ether. 

Discussion. — It  is  notable  that  the  patient  has  no  symptoms 
at  all  between  the  attacks  of  vomiting;  that  is,  between  the  menstrual 
periods.  Were  there  any  organic  lesion  in  the  stomach  it  would  be 
almost  certain  to  show  itself  between  times.  It  might  well  be  aggra- 
vated during  menstruation,  but  would  not  be  confined  to  that  time. 
The  negative  results  of  physical  examination  go  to  strengthen  the 
assumption  of  a  normal  stomach. 

Can  we  attribute  the  vomiting  to  retroversion  of  the  uterus? 
I  do  not  think  so.  There  seems  to  be  no  evidence  to  show  that 
retroversion,  per  se,  can  produce  this  or  any  other  s3rmptoms.  The 
chief  lesson  of  the  case  seems  to  me  to  be  that  violent  retching  from 
any  cause — for  example,  from  sea-sickness — may  produce  hematemesis. 

Outcome. — The  patient  left  the  hospital  on  the  26th  in  good  con- 
dition. 

Case  147 

A  ladderman  in  a  fire  department,  thirty-three  years  of  age,  en- 
tered the  hospital  April  25,  1910.  The  patient  lost  one  sister,  one 
aunt,  and  one  uncle  of  tuberculosis.  One  brother  died  of  drink;  other- 
wise the  family  history  is  good.  Except  for  two  attacks  of  gonor- 
rhea, twelve  and  nine  years  ago,  he  has  always  been  well  until  the 
present  illness. 


362  DIFFERENTIAL  DIAGNOSIS 

Eighteen  months  ago  he  had  a  feeling  of  distress  and  heaviness 
in  his  stomach,  as  if  something  was  rolKng  about  there.  Vomiting 
relieved  this  for  a  time,  and  now  he  makes  himself  vomit  whenever 
he  feels  any  such  trouble.  The  first  attack  lasted  about  three  weeks 
and  was  accompanied  by  lack  of  appetite.  Since  then  he  has  had 
about  a  dozen  similar  attacks,  lasting  from  three  days  to  three  weeks. 
Between  attacks  he  feels  perfectly  well  and  eats  all  foods  very  heartily. 
He  thinks  the  attacks  are  brought  on  by  eating  too  much,  or  by  eating 
something  which  disagrees  with  him,  and  that  they  are  usually  pre- 
ceded by  more  constipation  than  is  his  usual  habit.  He  never  has  any 
severe  pain  in  the  attacks,  only  a  dull  ache  at  the  pit  of  the  stomach 
and  in  the  left  hypochondrium.  Sometimes  he  vomits  unchanged 
food  eaten  twelve  hours  before.  Three  months  ago,  for  the  first  time, 
he  raised  a  large  amount  of  bright  blood.  The  last  attack,  seven 
weeks  ago,  began  after  a  drinking  bout. 

In  eighteen  months  he  has  lost  40  pounds.  Following  each  at- 
tack he  has  profuse  cold  sweats  at  night.  For  two  weeks  he  has  had 
a  hard  dry  cough  with  slight  expectoration,  frequently  blood-tinged. 
During  attacks  he  is  very  nervous  and  passes  urine  three  or  four  times 
each  night. 

Physical  examination  showed  good  nutrition  despite  evident  loss 
of  weight.  His  skin  became  cyanotic  when  he  was  asleep,  other- 
wise it  was  of  good  color.  His  pupils  were  small,  circular,  equal,  and 
reacted  very  slightly  to  light.  Glands  and  reflexes  were  normal.  Heart 
negative.  Lungs  negative,  save  for  a  few  fine  rales  and  diminished 
breathing  at  the  bottom  of  the  right  axilla.  The  stools  were  positive 
to  guaiac  only  on  the  27th  of  April.  On  the  other  days  of  his  two  and 
a  half  weeks'  stay  they  were  negative.  He  had  no  fever  during  this 
period,  and  his  blood  and  urine  were  negative.  The  sputum  was 
twice  examined  for  tubercle  bacilli  with  negative  results.  Wasser- 
mann  reaction  negative.  On  gastric  ulcer  diet  he  made  an  uninter- 
rupted recovery  and  left  the  hospital  on  the  12  th  of  May. 

The  patient  re-entered  the  hospital  September  2  2d  with  a  diag- 
nosis made  by  Dr.  H.  F.  Hewes  of  gastric  ulcer.  Since  leaving  the 
hospital  he  had  worked  only  three  weeks,  vomited  much,  and  been 
treated  mostly  by  gastric  lavage.  At  this  time  he  admitted  that  he 
had  had  sKght  pains,  quickly  darting  into  his  calves  and  out  again, 
and  that  in  the  previous  winter  and  for  the  past  two  or  three  weeks  he 
has  had  a  good  deal  of  pain  below  his  left  shoulder-blade,  mostly  on 
moving  his  arms.  For  the  past  year  he  has  had  slight  difficulty  in 
starting  micturition.     Knee-jerks   and   Achilles'   jerks   were   active, 


HEMATEMESIS  363 

the  right  greater  than  the  left.  At  this  time  the  right  pupil  was  larger 
than  the  left,  otherwise  they  were  as  before.  The  stools  were  four 
times  negative  to  guaiac;  the  sputa  three  times  negative  to  tubercle 
bacilli.  He  showed  no  temperature  reaction  after  7  mg.  of  old  tuber- 
culin. 

Discussion. — Despite  the  family  history  of  tuberculosis,  the  two 
weeks  of  dry  cough  with  blood-tinged  sputa,  the  loss  of  weight,  and 
the  presence  of  night-sweats,  we  have  no  good  reason  to  attribute  this 
patient's  symptoms  to  tuberculosis.  Night-sweats  may  result  from 
any  disease  which  produces  exhaustion,  with  or  without  fever.  The 
popular  belief  that  night-sweats  mean  phthisis  is  justified  only  to  the 
extent  that  phthisis  is  in  all  probability  the  commonest  cause  of  such 
sweats.     Nevertheless,  there  are  many  others. 

The  salient  feature  of  the  case  seems  to  be  the  occurrence  of  a 
dozen  or  more  attacks,  lasting  from  three  to  twenty-one  days,  char- 
acterized by  gastric  distress  and  vomiting.  Although  these  attacks 
are  by  the  patient  attributed  to  bad  diet  or  to  constipation,  there 
seems  no  good  reason  to  agree  with  him  on  this  point.  There  are 
some  doubtful  physical  signs  in  the  lungs,  but  it  seems  very  improb- 
able that  these  signs  are  the  cause  of  his  troubles  or  have  anything 
particular  to  do  with  them,  for  the  gastric  symptoms  are  paroxysmal 
with  long  intervals  of  good  health  between,  and  stomach  symptoms  of 
this  type  are  rarely,  if  ever,  produced  by  lung  trouble. 

The  condition  of  his  pupils  should  lead  us  to  make  careful  search 
for  evidences  of  tabes,  even  though  the  knee-jerks  are  normal  and 
the  Wassermann  reaction  negative  in  the  circulating  blood.  In 
such  a  patient  we  should  always  examine  the  spinal  fluid  and  look 
carefully  for  patches  of  anesthesia  or  hj^peresthesia. 

At  the  time  of  his  second  entrance  the  evidence  pointing  to  tabes 
was  much  clearer,  and  we  need  have  no  considerable  doubt  of  that 
diagnosis. 

Outcome. — Dr.  E.  W.  Taylor  pronounced  the  diagnosis  tabes.  The 
patient  sweat  profusely  at  night  during  most  of  his  week  in  the 
hospital.  Systolic  blood-pressure  at  entrance  was  160.  He  ate 
very  well  during  the  whole  of  his  stay  this  time.  His  condition  was 
explained  to  him  when  he  left  the  hospital  on  the  ist  of  October. 

The  patient  was  seen  in  January,  1913,  and  stated  that  his  vomit- 
ing had  now  ceased,  as  it  had  been  cured  by  a  Chinese  doctor.  The 
treatment  given  him  at  the  Massachusetts  General  did  not  help  him 
at  all,  and  after  leaving  the  hospital  he  could  scarcely  w^alk  and  did 
no  work  for  six  months.      Since  that  time,  however,  he  has  been 


364  DIPFERENTIAL  DIAGNOSIS 

able  to  work,  and  his  appetite,  bowels,  and  sleep  are  now  normal. 
Oflf  and  on  he  has  attacks  of  frequent  micturition,  and  about  every 
five  or  six  weeks  he  has  a  pain  over  his  right  kidney  and  his  urine 
looks  like  pea  soup.     These  symptoms,  however,  do  not  disable  him. 

Case  148 

A  Swedish  dressmaker  of  thirty  entered  the  hospital  September 
29,  1 910.  The  patient  has  had  slight  heartburn  and  epigastric  pain 
for  a  few  days  at  a  time,  once  or  twice  a  year,  for  the  past  ten  years. 
She  has  thought  nothing  of  it,  and  has  always  been  very  well  and 
strong  up  to  a  year  ago,  when  she  began  to  have  almost  daily  tender- 
ness and  burning  pain  in  the  epigastrium,  the  latter  coming  from  one- 
half  to  one  hour  after  meals  and  reheved  by  soda.  She  has  vomited 
two  or  three  times  a  week,  sometimes  a  quart  at  a  time,  but  has  never 
noticed  in  the  vomited  matter  food  eaten  the  day  before.  Two  days 
ago,  for  the  first  time,  she  vomited  blood,  small  amounts  frequently, 
and  yesterday  she  vomited  half  a  basinful.  This  morning  she  brought 
up  the  same  amount.  She  has  worked  continuously  until  this  bleed- 
ing began  and  has  lost  no  weight.  Immediately  on  entrance  to  the 
hospital  she  vomited  10  or  12  ounces  more  of  blood.  She  was  given 
^  grain  of  morphin,  subcutaneously,  repeated  every  four  hours  when 
necessary,  to  control  vomiting.  All  food  was  omitted,  and  she  was 
given  6  ounces  of  salt  solution  every  four  hours  by  rectum. 

Physical  examination  was  wholly  negative,  save  for  a  soft  systolic 
murmur,  loudest  at  the  apex.  The  stools  showed  a  strong  reaction 
for  guaiac  every  day  until  October  5th,  after  that  none.  The  urine 
was  negative.  The  red  corpuscles  at  entrance  were  just  below 
4,000,000,  and  in  the  course  of  the  next  two  weeks  sagged  nearly 
to  3,000,000.  The  hemoglobin  remained  all  the  time  about  70  per 
cent.  The  leukocytes  at  entrance  numbered  15,000,  with  80  per  cent, 
of  polynuclears.  The  appearance  of  the  red  corpuscles  at  entrance 
was  wholly  normal;  no  achromia.  She  had  no  fever  in  three  weeks' 
observation.     Blood-pressure,  105  mm.  Hg. 

Discussion. — ^Any  patient  who  has  had  stomach  trouble  for  ten 
years,  off  and  on,  and  at  the  end  of  that  time  brings  up  from  the 
stomach  a  large  amount  of  blood  and  shows  a  well-marked  anemia 
thereafter  is  rightly  assumed  to  have  a  peptic  ulcer  until  evidence 
is  adduced  to  the  contrary.  Cirrhosis  of  the  liver  is  always  a  possible 
source  of  mistake  in  such  a  case,  but  in  a  woman  of  this  age,  who 
denies  all  contact  with  alcoholic  liquor,  the  chance  of  mistake  is  not 
very  great.     The  rarer  and  more  serious  causes  of  hematemesis  are 


HEMATEMESIS         *  365 

all  of  them  highly  improbable  in  a  patient  who  is  at  work  when  the 
bleeding  begins,  and  seems,  in  most  respects,  healthy  on  physical 
examination. 

It  may  here  be  noted  that  the  physical  examination  of  the  ab- 
domen in  cases  of  peptic  ulcer  is  almost  invariably  negative.  The 
only  objective  evidence  we  have  is  the  evidence  of  hemorrhage  and 
that  furnished  in  some  cases  by  bismuth  x-ray  examination  or  by  the 
string  test.  It  should  never  surprise  us  to  find  the  abdomen  soft  and 
free  from  tenderness,  as  in  perfect  health. 

Outcome. — On  the  3d  of  October  crackers  and  milk  in  small 
amounts  were  begun,  and  thereafter  the  amount  of  food  was  steadily 
increased.  She  had  no  symptoms  or  complaints,  and  October  20th 
seemed  entirely  well  and  left  the  hospital.  Three  years  later  she 
reported  that  she  had  no  further  trouble  and  was  perfectly  well. 
Her  appearance  confirmed  this  opinion. 

Case  149 

A  housewife  of  twenty-five  entered  the  hospital  February  16,  1911. 
The  patient's  family  history  is  negative.  Her  general  health  has  been 
always  poor.  Previous  to  the  age  of  twenty-one  she  had  a  great  deal 
of  diarrhea. 

For  the  past  three  weeks  has  had  a  great  deal  of  indigestion  and 
heartburn,  with  considerable  hematemesis,  the  dates  and  amounts  not 
being  clear.  About  a  week  ago  she  began  to  vomit  three  or  four 
times  a  day  for  the  relief  of  epigastric  distress.  Yesterday  she  sud- 
denly vomited  a  quart  of  pure  blood,  followed  by  small  amounts  at 
intervals  since.     She  worked  until  two  days  ago. 

While  this  history  was  being  taken  she  raised  30  c.c.  of  bright 
blood.  On  the  afternoon  of  the  i6th  she  also  passed  much  blood  by 
rectum;  her  pulse  rose  to  156.  She  was  kept  under  morphin  and  the 
bleeding  ceased  until  the  19th,  when  about  160  c.c.  were  raised  and  a 
few  clots  passed  by  rectum.  Tarry  stools  were  passed  on  the  20th  and 
2ist.  She  was  given  salt  solution  under  the  skin  and  seepage,  15  per 
cent,  glucose  in  normal  salt  solution,  500  c.c.  daily.  On  the  2 2d  she 
was  fed  small  quantities  of  milk  and  lime-water  and  did  well  there- 
after.    No  cause  was  found  for  the  continued  fever. 

On  the  first  of  March  the  nurses  suddenly  noticed  that  she  had  a 
fixed  stare  and  did  not  seem  to  breathe.  The  pulse  was  very  small, 
but  not  rapid.  A  few  minutes  later  the  left  arm  and  leg  began  to 
twitch,  and  this  continued  several  minutes.  Five  minutes  later 
she  was  crying,  semirational,  objecting  to  having  the  pupils  tested, 


366 


DIFFERENTIAL  DIAGNOSIS 


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Fig.  126. — Blood  changes  in  Case  149. 

but  the  left  was  considerably  larger  than  the  right.     She  complained 
of  a  very  queer  feeling  in  her  left  hand,  and  for  a  minute  or  two  ground 


HEMATEMESIS 


367 


her  teeth  furiously.  Within  an  hour  she  seemed  as  well  as  usual. 
At  that  time,  March  ist,  the  first  physical  examination  was  done 
and  showed  nothing  remarkable  except  a  much  enlarged  spleen,  reach- 
ing 7  cm.  below  the  ribs.  Splenic  dulness  18  cm.  in  length.  On  the 
2d  of  March  there  was  ankle-clonus  on  both  sides,  especially  on  the 
left,  and  her  general  restlessness  and  poor  condition  had  increased. 
The  course  of  her  blood  chart  is  shown  in  Fig.  126.  The  stained  smear 
showed  nothing  remarkable  except  achromia  and  stippling.  The 
red  cells  were  not  enlarged.  At 
times  normoblasts  were  numer- 
ous, some  of  them  showing  mi- 
tosis. The  fundus  oculi  was 
negative.  Urine  negative.  Tem- 
perature as  ,in  Fig. -127.  Sys- 
tolic blood-pressure,  95  mm.  Hg. 

On  the  3d  of  March  she  was 
transfused,  the  blood  being  al- 
lowed to  flow  twenty-five  minutes 
until  the  donor  became  pale  and 
restless,  with  sighing  respiration. 
The  patient  was  intensely  pale 
at  the  beginning  of  the  operation, 
but  after  it  her  color  had  re- 
turned and  her  respiration  was 
deep  and  regular.  She  slept 
well  the  next  night  and  was 
very  hungry.  After  that  she 
very  rapidly  improved.  Before  operation  she  was  practically  mor- 
ibund, gasping  for  breath,  and  very  pale. 

Discussion. — Association  of  splenic  enlargement  with  the  vomit- 
ing of  blood  has  been  recognized,  since  Osier's  classical  paper,i  to  point 
with  a  considerable  certainty  to  the  diagnosis  of  splenic  anemia.  In 
most  cases  the  hemorrhage  is  due  to  mechanical  causes  related  to  the 
splenic  enlargement  and  to  obstruction  of  venous  return,  yet  the 
bleeding  may  result  from  any  of  the  causes  ordinarily  associated  with 
cirrhotic  liver.  That  the  patient  has  had  three  weeks  of  dyspepsia, 
and  has  suffered  a  good  deal  in  her  earlier  years  from  diarrhea,  does 
not  invalidate  our  theory  of  splenic  anemia  nor  does  the  convulsion 
of  March  ist  upset  the  diagnosis.  Such  a  convulsion  may  well  be 
associated  with  the  patient's  anemia. 

^  Transactions  of  the  Association  of  American  Physicians,  1902. 


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Fig.  127. — Chart  of  Case  149. 


368  DIFFERENTIAL  DIAGNOSIS 

The  best  that  can  be  said  against  the  diagnosis  of  splenic  anemia 
is  that  that  disease  itself  represents  a  very  loose  and  unsatisfactory- 
grouping  of  s>Tnptoms.  Of  its  pathogenesis  we  know  little  or  nothing. 
We  are  not  even  certain  that  there  is  any  such  entity.  Many  of  the 
cases  reported  under  this  title  are  doubtless  due  to  malaria,  syphilis, 
or  to  the  ordinary  type  of  hepatic  cirrhosis.  I  say  to  the  ordinary 
type,  since  it  is  generally  admitted  that  what  we  call  splenic  anemia 
may  be  only  the  first  stages  of  a  disease  which  in  its  later  course  is 
indistinguishable  from  liver  cirrhosis.  To  this  sequence  of  events — 
primary  splenic  enlargement,  with  anemia  and  subsequent  develop- 
ment of  interstitial  hepatitis — the  term  "Banti's  disease"  is  now  pretty 
firmly  attached,  but  there  is  much  that  is  unsatisfactory  in  our  knowl- 
edge of  this  disease,  as  well  as  in  the  so-called  splenic  anemia. 

The  life-saving  efficiency  of  transfusion,  as  recently  reintroduced 
into  medicine  through  the  technical  improvements  of  George  W.  Crile, 
has  not  as  yet  been  sufficiently  realized  by  the  medical  profession. 
Patients  die  every  week,  I  believe,  whose  fives  might  have  been 
saved  by  transfusion  of  blood.  Unfortunately,  even  in  communities 
where  the  importance  of  the  operation  is  recognized,  there  are  few 
surgeons  who  know  enough  to  do  it.  The  technic  of  the  operation 
has  recently  been  so  much  simplified  that  it  is  a  disgrace  to  our  pro- 
fession that  any  patient  should  be  without  the  benefits  to  be  derived 
from  transfusion.  The  operation  is  indicated  in  cases  of  posthemor- 
rhagic anemia,  when  the  patient  fails  to  show  a  prompt  or  satisfactory 
impetus  toward  regeneration  of  blood.  It  is  also  indicated  in  other 
forms  of  secondary  anemia,  where  an  operation  is  desirable,  but  is 
postponed  or  frowned  upon  because  of  the  patient's  anemia.  In 
such  cases  a  bad  surgical  risk  may  be  turned  into  a  good  one  by 
transfusion  properly  performed. 

A  third  and  less  common  indication  for  transfusion  is  uncon- 
trollable oozing  from  cutaneous  mucous  or  serous  surfaces. 

Outcome. — She  returned  to  the  ward  in  excellent  condition,  and 
after  two  and  a  half  weeks  of  uneventful  convalescence  was  allowed 
to  go  home.  The  course  of  her  blood  changes  during  this  time  is  seen 
in  Fig.  126.  It  was  noticeable  that  she  ran  a  slight  temperature  most  of 
the  time,  varying  between  99°  and  99.6°  F.  during  her  convalescence. 


CHAPTER  VI 
GLANDS 

ENLARGED  GLANDS  AND  WHAT  SIMULATES  THEM 

Not  all  palpable  glands  are  enlarged.  The  normal  wear  and  tear 
of  existence  in  civilized  communities  produces  enough  infection  or  sub- 
infection  to  bring  about  some  enlargement  of  the  glands  without  our 
being  able  to  say  that  any  disease  has  afflicted  the  individual  or  his 
glands.  It  is  a  mistake,  therefore,  to  suppose  or  to  state  that  glands 
are  enlarged  merely  because  we  feel  them,  and  it  means  nothing  to 
record  in  our  case  histories  that  they  are  palpable,  unless  in  some  very 
unusual  situation.  The  best  way  is  to  state  approximately  how  large 
the  glands  are.  In  general,  it  may  be  said  that  a  considerable  pro- 
portion of  all  adults  living  in  cities  have  in  their  groins  one  or  more 
glands  twice  the  size  of  a  pea.  In  the  axillae  glands  of  this  size  are  less 
common,  and  a  considerable  number  of  healthy  persons  have  none  that 
one  can  feel  at  all  in  that  situation.  The  same  is  true  of  the  neck  and 
epitrochlear  regions,  yet  it  must  be  recognized  that  palpable  epitroch- 
lear  glands,  while  less  common  than  palpable  inguinal  glands,  are 
nevertheless  not  at  all  rare  in  perfectly  healthy  persons,  and  should 
not  be  made  the  ground  of  any  suspicion  of  any  syphihtic  infection, 
as  has  been  the  custom  in  certain  chnics  here  and  in  Europe. 

It  is  a  very  famihar  fact  that  enlargement  of  the  inguinal  glands 
accompanies  infection  of  the  leg,  thigh,  or  genital  tract;  that  enlarge- 
ment of  the  axillary  glands  follows  infection  of  the  arm  and  of  certain 
parts  of  the  chest  wall;  that  enlargement  of  the  glands  of  the  neck  is 
associated  with  infection  of  the  mouth,  throat,  face,  or  scalp. 

Beyond  this,  the  attempt  is  often  made  to  associate  certain  groups 
of  cervical  glands  with  certain  drainage  areas,  but  in  practice  there  is 
seldom  any  such  actual  dehneation.  The  drainage  areas  surely  must 
cross  or  anastomose.  It  is  true,  nevertheless,  that  enlargement  of  the 
posterior  cervical  glands  behind  the  sternomastoid  is  very  frequently 
associated  with  syphilis  and  with  German  measles. 

So  much  is  relatively  clear.  Much  less  clean  cut  is  the  associa- 
tion of  certain  pelvic  and  abdominal  growths  with  enlargement  of  the 
inguinal  glands  and  of  certain  thoracic  growths  with  enlargement  of 

Vol.  11—24  ,    -  369 


370  DIFFERENTIAL  DIAGNOSIS 

the  axillary  or  cervical  glands.  In  many  cases  there  is  no  such  asso- 
ciation. The  pelvic  and  abdominal  growths  have  their  glandular 
metastases  in  the  mesentery  and  other  prevertebral  glands,  while 
infections  and  tumors  of  the  thoracic  cavity  affect  the  branchial 
and  tracheal  lymphatics.  This,  I  say,  is  the  rule,  and,  therefore, 
a  considerable  portion  of  all  the  glandular  enlargement  altogether 
escapes  our  notice  on  physical  examination.  We  can  rarely  reach 
the  deep  abdominal  glands  either  by  palpation  or  in  any  other  way, 
and  even  by  the  aid  of  x-ray  and  of  spinal  percussion  we  are  far  from 
certainty  in  the  diagnosis  of  enlarged  branchial  or  tracheal  glands; 
yet  these  sites  of  adenoid  tissue  must  always  be  present  in  the  physi- 
cian's mind.  He  must  never  think  of  the  neck,  axillae,  and  groins 
as  tJie  normal  sites  of  possible  glandular  enlargement,  but  only  as 
the  more  obvious  and  visible  sites. 

Cancer  of  the  stomach,  tuberculous  peritonitis,  the  gall-bladder 
infections,  peptic  ulcer  of  the  stomach  or  duodenum,  and  most 
of  the  abdominal  lesions^ which  present  the  greatest  difficulties  in 
diagnosis  do  not  produce,  as  a  rule,  any  glandular  enlargement  which 
we  can  recognize  on  physical  examination.  In  a  very  small  per- 
centage of  cases,  gastric  cancer  and  some  other  abdominal  neoplasms 
are  associated  with  a  glandular  metastasis  above  one  clavicle,  the  so- 
called  sentinel  gland.  Such  a  gland  should  always  be  felt  for  when 
we  are  in  doubt  about  a  diagnosis  of  malignant  disease  in  the  abdomen, 
and  if  any  such  gland  is  present  it  should  be  excised  and  examined 
microscopically  for  evidence  of  malignant  disease. 

Cervical  or  axillary  metastases  are  seen  with  considerable  fre- 
quency in  cancer  of  the  lung  and  pleura  and  in  lymphoblastoma  of  the 
mediastinal  glands,  yet  this  association  is  mysterious,  vague,  fickle, 
and  unreliable.  We  do  not  understand  why  it  occurs  as  often  and 
no  oftener. 

Another  point  hitherto  not  clearly  explained  is  the  occasional  ex- 
tension of  a  streptococcic  sepsis,  starting  in  a  tonsil,  not  only  to  the 
cervical  glands,  but  to  the  axillary  glands  as  well.  I  have  several 
times  seen  axillary  suppuration  containing  a  pure  culture  of  strepto- 
cocci in  association  with  a  similar  cervical  adenitis,  apparently  originat- 
ing in  a  streptococcic  sore  throat  of  the  mild  epidemic  type.  This 
brings  me  to  another  problem  regarding  the  glandular  hypertrophies 
and  inflammations  of  the  tonsillar  ring.  It  is  ordinarily  assumed  that 
when  a  tonsillar  inflammation  arises  it  has  been  acquired  through  some 
food  that  has  passed  over  the  tonsil  or  through  the  inspired  air  and 
its  contact  with  the  tonsil.     In  other  words,  it  is  through  the  faucial 


Glands- 


met  ASTATIC  (NEOPLASM) 

SEPTIC    ADENITIS    (INCLUDING    SEPSIS    FROM    CUTANEOUS    AND    DENTAL 
DISEASE) 


SYPHILIS  ■^^■■■■■■■■■■^^^^^I^^^B  5145 

ADENITIS  (UNKNOWN!  '■'  ^,^^ 

CAUSE)  /    ^^^^^^^^^— 

TUBERCULOUS  ADEN-)     _^^^ 
ITIS  I    ^^  ^^^ 

HODGKIN'S      DISEASE  1 
AND  LYMPHOMA         J 

LYMPHATIC  LEUKEMIA    I  27 


^  These  figures  are  taken  from  the  records  of   the  Out-patient  Department  and 
include  no  ward  cases. 


371 


372  DIFFERENTIAL  DIAGNOSIS 

surface  of  the  tonsil  that  that  gland  becomes  inflamed.  This  assump- 
tion is  very  natural,  but  not  necessary.  It  is  natural  because  the  ton- 
sillar crypts  open  into  the  fauces  and  because  foci  of  pus  or  bacterial 
growth  are  usually  to  be  found  in  these  crypts.  One  naturally  assumes, 
therefore,  that  infection  has  gone  into  the  cry])t  through  the  mouth 
of  the  crypt.  But  this  is  obviously  a  superficial  view.  Tonsillar  in- 
flammation is  by  no  means  confined  to  the  crypts  and  often  has  no 
obvious  connection  with  them.  The  so-called  quinsy  sore  throat  or 
peritonsillar  abscess  has  its  origin  very  deep  in  the  tissues,  far  from 
their  faucial  surface.  How  do  we  know  that  the  infection  does  not 
come  from  within  rather  than  from  without?  Such  a  question  has 
often  occurred  to  me  when  I  have  observed  in  a  child,  first,  endocardi- 
tis or  arthritis,  and  later  a  tonsillitis.  Such  a  sequence  suggests  that 
an  infection  widely  generalized  within  the  body  has  been  carried  first 
to  the  heart  or  to  the  joints  and  later  to  the  tonsillar  tissues.  Have 
we  any  good  reason  to  believe  that  the  tonsils  are  not  often  infected 
in  this  way,  from  within  rather  than  from  without?  I  do  not  see  that 
we  have.  No  one  supposes,  I  take  it,  that  similar  glandular  enlarge- 
ments of  the  intestine  (Peyer's  patches  and  solitary  follicles)  are  pro- 
duced through  the  entrance  of  typhoid  bacilH  from  the  interior  of  the 
intestine.  It  is  generally  assumed  that  the  typhoid  bacilli,  which  we 
can  usually  isolate  from  the  circulating  blood,  are  carried  by  the 
blood-stream  and  by  the  lymphatics  to  all  parts  of  the  body  and 
appear  in  the  lymph-glands  of  the  intestine  from  within  rather 
than  from  without.  Why  should  not  the  same  be  true  of  tonsillar 
infection? 

In  addition  to  the  foci  of  lymphadenoid  tissue  which  have  been 
mentioned  in  the  foregoing  paragraphs,  there  are,  in  all  probability, 
minute  collections  of  similar  tissue  scattered  in  all  parts  of  the  body, 
including  the  serous  surfaces  and  subcutaneous  tissues.  We  get  no 
clinical  evidence  of  the  existence  of  these  minute  foci,  except  in 
lymphoid  leukemia  and  multiple  lymphoblastoma.  In  these  condi- 
tions the  minute  foci  just  referred  to  become  enormously  enlarged,  and 
the  subcutaneous  group  show  beneath  the  skin  as  lumps  of  various 
sizes  scattered  diffusely  over  the  body  surface.  Similar  nodules  ap- 
pear in  the  internal  ear,  producing  deafness;  in  the  orbit,  displacing  the 
eyeball,  and  in  many  other  less  conspicuous  situations.  Under  such 
conditions  the  body  seems  to  be  riddled  or  honeycombed  with  lymph- 
adenoid  tissue,  of  whose  presence  we  are  not  ordinarily  aware. 


GLANDS  373 

CLINICAL  GROUPINGS 

Glandular  enlargements  in  the  neck,  axillaj,  and  groins  are  ordinar- 
ily of  four  types,  so  far  as  they  can  be  studied  by  the  ordinary  methods 
of  physical  examination;  that  is,  without  the  excision  of  a  gland: 

(i)  Simple  glandular  hypertrophy. 

(2)  Glandular  hypertrophy  with  inflammation  and  with  or  without 
suppuration. 

(3)  Glandular  enlargement  with  caseation. 

(4)  Glandular  enlargements  of  the  hard,  nodular  type. 

The  enlargements  of  the  first  type  are  seen  in  syphilis,  in  lympho- 
blastoma, with  or  without  leukemia,  and  in  many  cases  without  known 
cause. 

The  septic  type  of  adenitis  is  commonest  in  connection  with  ton- 
sillitis and  other  inflammations  of  the  mouth  and  throat,  also  in  septic 
processes  of  an  arm  or  one  or  another  extremity,  and  in  gonorrhea.  A 
peculiar  type  belonging  in  this  group  is  the  idiopathic  axillary  ab- 
scesses (non- tuberculous),  a  suppuration  which  arises  without  known 
cause,  deep  in  the  axillary  tissues,  pushes  forward  to  the  superimposed 
axillary  glands,  so  that  the  pus  concealed  beneath  them  is  often  not 
suspected. 

Caseous  glands  are  generally  associated  with  tuberculosis. 

The  hard,  nodular  glands  are  usually  neoplastic  and  may  some- 
times contain  cartilaginous  or  even  bony  substances. 

But,  although  these  clinical  groups  guide  us  in  many  cases  to  a 
sufficiently  accurate  and  prompt  diagnosis,  there  are  many  other  cases 
in  which  we  are  wholly  at  a  loss  to  decide  what  type  of  adenitis  is 
present,  unless  a  gland  is  excised  and  examined  histologically.  This 
should  be  done  much  more  frequently  than  it  is.  As  a  rule,  some  one 
of  the  enlarged  glands  or  some  portion  of  one  is  placed  so  superficially 
that  it  can  be  taken  out  under  local  anesthesia  without  any  consider- 
able pain  or  hemorrhage. 

The  other  characteristics  of  the  glands  are  less  valuable  in  differ- 
ential diagnosis.  It  usually  helps  us  very  httle  to  know  whether  the 
glands  are  discrete  or  matted  together,  and  almost  any  of  the  four  types 
above  mentioned  may  be  either  hard  or  soft,  either  attached  to  the 
skin  or  freely  movable  beneath  it.  Nevertheless,  it  is  true  that  the 
septic  and  tuberculous  types  are  more  likely  to  involve  the  skin 
than  either  of  the  others.  Tenderness  and  redness  of  the  overlying 
skin  are  rarely  seen  except  in  the  inflammatory  type  of  adenitis, 
but  occasionally  an  inflammatory  reaction  occurs  about  a  l}Tiipho- 
blastoma. 


374  DIFFERENTIAL   DIAGNOSIS 

NOMENCLATURE  OF  GLANDULAR  TUMORS 

The  weight  of  opinion  among  competent  pathologists  inclines 
more  and  more  toward  a  simplification  and  unification  of  the  terms 
ordinarily  applied  to  the  new  growths  involving  lymph-glands.  The 
terms  lymphoma,  malignant  lymphoma,  lymphosarcoma,  small  round- 
cell  sarcoma,  pseudoleukemia,  lymphocytoma,  leukemic  infiltration, 
leukosarcoma,  and  others  appear  to  represent  different  varieties 
of  the  same  pathologic  lesion.  The  growths  of  the  firmer  and  more 
chronic  type  are  apt  to  be  called  Hodgkin's  disease,  especially  if  they 
originate  in  the  superficial  lymph-glands  of  the  neck,  axillae,  and  groins. 
The  same,  originating  in  the  mediastinal  or  in  the  abdominal  glands, 
is  apt  to  be  spoken  of  as  a  "lymphosarcoma,"  while,  if  the  spleen  is 
notably  enlarged,  the  term  "pseudoleukemia"  is  applied,  so  long  as  the 
blood  remains  normal.  The  same  disease  may  be  dubbed  "leukemia"  a 
week  later,  when  the  blood  has  become  invaded  with  cells  like  those 
of  the  tumor.  I  shall  follow  in  this  book  the  terminology  of  Frank  B. 
Mallory.  He  names  all  such  tumors  by  their  t^-pe  cell,  the  lympho- 
blast,  the  cell  occurring  normally  in  the  germ  centers  of  lymph-nodes 
and  l)Tnphadenoid  tissue.  Tumors  of  this  group  are  differentiated 
both  from  myeloblastoma — the  histologic  basis  of  myeloid  leukemia 
with  its  subvariety,  chloroma — and  from  myeloma,  a  tumor  arising 
only  within  the  bone-marrow  and  never,  associated  with  leukemic 
blood. 

WHAT  OTHER  LUMPS  MAY  BE  MISTAKEN  FOR  GLANDS? 

I  have  known  fatty  tumors,  subcutaneous  cysts,  abscesses,  and 
the  infiltration  of  actinomycosis  to  be  mistaken  for  enlarged  glands, 
but  such  mistakes  are  not  common.  Ordinarily,  the  soft  lobulated 
surface  of  the  fatty  tumor  and  its  situation  away  from  the  ordinary 
sites  of  glandular  enlargement  makes  it  easy  to  identify. 

Cysts,  especially  those  occurring  in  the  neck,  are  less  easily  recog- 
nized, but  they  are  rare,  and,  as  a  rule,  their  position  and  fluctuating 
consistency  makes  clear  their  origin. 

Abscesses  and  subcutaneous  infiltrations  are  much  less  circum- 
scribed and  definite  in  outline  when  compared  with  glands. 

GLAND  PUNCTURE 

To  introduce  a  hollow  needle  into  the  substance  of  an  enlarged 
gland  and  withdraw  gland  juice  has  for  some  years  been  an  important 
diagnostic  procedure  in  cases  of  suspected  trypanosomiasis,  but  the 


GLANDS  375 

procedure  has  not  yet  come  into  any  general  use  as  a  part  of  the  diag- 
nosis of  other  diseases.  It  seems  to  me  it  should  be  more  frequently 
employed,  as  by  such  means  the  organisms  of  syphihs,  tuberculosis, 
and  the  more  ordinary  varieties  of  septicemia  could  perhaps  be  iden- 
tified in  culture  or  cover-slip. 

Case  150 

•  A  clerk  of  twenty-nine  entered  the  hospital  December  7,  1905. 
For  the  past  nine  months  a  bunch  has  been  noticed  in  the  left  side  of 
the  neck.  It  made  its  appearance  rather  suddenly  and  was  at  first 
about  as  big  as  a  walnut.  Three  weeks  ago  he  was  thrown  out  of  a 
carriage;  since  then  the  bunch  has  grown  larger.  For  a  few  days  he 
has  had  some  trouble  in  swallowing. 

Physical  examination  is  negative  save  for  scattered  squeaks  in 
both  lungs,  and  in  the  left  side  of  the  neck  an  irregular-shaped,  elastic 
mass  the  size  of  a  child's  fist,  slightly  tender,  not  adherent  to  the  skin, 
but  not  freely  movable.  No  fever.  Blood  and  urine  normal.  Diag- 
nosis, tuberculous  glands  of  the  neck. 

Discussion. — Unlike  tuberculosis  or  Hodgkin's  disease,  the  lump 
present  in  this  case  has  been  recognized  for  nine  months  without  any- 
thing on  the  other  side  of  the  neck.  Another  point  of  peculiarity  in 
this  case  is  the  apparently  sudden  appearance  of  the  bunch.  I  say 
"apparently  sudden,"  as  we  must  be  on  our  guard  lest  the  patient  quite 
unintentionally  misleads  us  upon  this  point.  I  have  repeatedly  had 
patients  tell  me  most  earnestly  and  in  good  faith  that  a  certain  lump 
had  appeared  over  night,  although  investigation  showed  that  the 
lump  in  question  was  a  portion  of  the  bony  skeleton  which  had  pre- 
sumably existed  for  forty  years  or  more. 

But  if  the  patient  is  correct  in  believing  that  this  bunch  has  made 
its  appearance  suddenly,  we  may  be  somewhat  suspicious  that  it  is 
not  a  gland  at  all,  especially  as  there  is  nothing  in  the  mouth  to  sug- 
gest an  origin. 

Outcome. — At  operation,  December  8th,  the  supposed  gland  was 
dissected  out.  It  was  found  to  be  adherent  at  its  base,  and  in  freeing 
it  the  gland  broke,  with  the  discharge  of  2  ounces  of  watery  pus. 
The  wound  healed  normally.  At  the  end  of  the  operation  the  diag- 
nosis is  written,  "Removal  of  tiiberculous  glands  from  the  neck." 
Microscopic  examination  by  Dr.  W..  F.  Whitney  showed  a  cystic 
tumor,  the  inner  surface  of  which  was  lined  by  low,  fiat  epithehum,  the 
outer  wall  composed  of  an  extremely  vascular  connective  tissue,  /.  e., 
branchial  cyst. 


376 


DIFFERENTIAL  DIAGNOSIS 


Remarks. — Branchial  cysts  are  of  three  t>pes: 

(i)  Those  that  communicate  with  the  mouth  or  throat  through  a 
sinus,  so  that  pressure  upon  the  cyst  forces  fluid  into  the  patient's 
mouth. 

(2)  Those  opening  externally  in  the  neck  and  discharging  more  or 
less  intermittently  their  contents. 

(3)  Those  which  are  blind  at  both  ends  and  have  no  opening  at 
all. 

In  the  present  case  the  cyst  was  apparently  of  the  latter  type.  I 
saw  not  long  ago  a  patient  with  a  branchial  cyst  of  the  first  type,  which 
was  about  the  size  of  an  egg,  situated  above  the  left  clavicle;  on 
pressing  it  the  patient  was  conscious  of  a  gush  of  disagreeably  tasting 
fluid  in  the  mouth. 

Case  151 

A  laborer  in  a  factory,  age  fifty-two,  entered  the  hospital  July 
12,  1904.     The  patient  has  never  been  sick  before  and  denies  venereal 


disease. 

month. 


Fig.  128. — Chest  signs  in  Case  151. 

He  drinks  beer  and  whisky  freely  and  is  drunk  about  once  a 
July  3d  he  noticed  a  lump  in  his  left  armpit.      He  has  had 


GLANDS  377 

no  previous  cut  upon  his  arm  or  hand  or  any  sores.  July  6th  he  came 
to  the  hospital  for  advice  about  it.  A  mass  the  size  of  a  plum  was  felt 
in  the  left  axilla,  freely  movable,  not  tender  or  fluctuant,  with  no  redden- 
ing above  it.  Lungs  as  in  Figs.  1 28  and  129.  Temperature  as  in  Fig.  130. 
Poultices  were  applied  to  the  axilla  and  the  patient  was  kept  in  bed. 
He  complained  of  headache  and  the  spleen  was  palpable.  It  was  sub- 
sequently learned  that  he  had  chills  and  pain  at  the  onset  of  the  swell- 
ing in  the  axilla.  The  white  cells  were  9900.  Widal  reaction  nega- 
tive. Except  for  the  abnormalities  above  mentioned,  physical  ex- 
amination, including  the  urine,  was  negative.    A  stained  smear  of  the 


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Fig.  129. — Chest  signs  in  Case  151. 

blood  showed  82  per  cent,  of  polynuclears  and  no  eosinophils.  Widal 
continued  negative.  By  the  24th  of  July  the  swelUng  in  the  axilla  had 
disappeared.  Widal  reaction  was  still  negative.  There  was  no  reac- 
tion to  tuberculin — 10  mg.  O.  T. 

The  patient  left  the  hospital  July  27  th  and  remained  well  until 
August  nth,  when  the  lump  reappeared  in  the  left  axilla — red,  hot, 
and  tender.  At  the  same  time  he  began  to  cough  and  raise  yellow 
sputa,  with  fever  (Fig.  131).  Five  weeks  ago  he  weighed  160  pounds; 
now,  149  pounds.     The  glands  were  palpable,  but  not  enlarged  in  the 


378 


DIFFERENTIAL  DIAGNOSIS 


neck,  groins,  and  right  axilla.  The  left  axilla  was  filled  by  a  mass  of 
matted  glands,  hot  and  tender.  This  time  the  spleen  was  not  palpable. 
The  blood  was  negative.  By  the  i  yth  the  tenderness  and  inflammation 
was  gone  from  the  glands,  but  the  mass  seemed  larger. 

Discussion.— This  patient  has  been  conscious  of  a  lump  in  the  axilla 
for  nme  months  only,  but  on  examination  he  turns  out  to  have,  in 
addition,  an  enlargement  of  the  spleen,  a  fever  without  leukocytosis, 
a  negative  Widal  reaction  and  tuberculin  reaction,  and  no  recognizable 
focus  of  infection  or  source  of  neoplastic  metastasis.  At  the  time  of 
the  patient's  entry  the  spleen  is  not  felt  and  the  axillary  lump  shows 
all  the  evidences  of  acute  inflammation.     Moreover,  it  is  now  asso- 


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ciated  with  glands  in  the  neck,  in  the  other  axilla,  and  in  the  groins. 
At  this  time  diagnosis  is  much  more  possible  than  at  the  time  of  his 
first  appearance.  Considering  the  generalization  of  the  glandular 
lumps  and  the  absence  of  any  known  infection  prior  to  the  glandular 
infection  itself,  it  seems  probable  that  we  are  dealing  with  a  case  of 
lymphoblastoma  of  rather  an  acute  type,  associated  with  secondary 
infection  of  the  gland. 

Outcome. — On  the  19th  a  large  infiltrating  mass,  extending  deep 
under  the  pectoral  and  down  the  great  vessels,  was  exposed  by  opera- 
tion. A  piece,  4  by  3  cm.,  was  removed,  and  consisted  of  hard, 
gray  tissue  with  a  few  necrotic  areas.     Examination  by  Dr.  Channing 


GLANDS  379 

C.  Simmons  showed  the  structure  of  Hodgkin's  disease.  Dr.  J.  H. 
Wright  concurred  in  the  description  given  by  Dr.  Simmons,  but 
preferred  to  regard  the  tumor  as  a  form  of  lymphosarcoma.  The 
wound  healed  well,  and  the  patient  left  the  hospital  on  the  28th. 

Remarks. — I  have  given  the  terminology  of  the  last  paragraph 
exactly  as  it  was  written  in  the  hospital  records,  but  at  the  present 
time  I  think  both  these  gentlemen  would  use  Dr.  Mallory's  term, 
"lymphoblastoma." 

Case  152 

An  Italian  teamster  of  twenty-five  entered  the  hospital  March  7, 
191 1.  He  has  a  negative  family  history  and  past  history.  A  year 
ago  he  noticed  a  swelling  below  his  right  ear  and  one  below  his  Adam's 
apple.  Both  of  these  have  increased  in  size  since.  He  has  had  a  good 
deal  of  trouble  with  his  teeth  in  the  past  two  years.  He  sweats  much 
at  night  and  has  occasional  buzzing  in  his  ears. 

Physical  examination  showed  a  few  pea-sized  glands  in  the  poste- 
rior cervical  triangles.  In  the  region  of  the  thyroid  was  a  symmetric, 
bilateral,  crescent-shaped  tumor,  about  2  by  i^  inches,  moving  upward 
when  the  patient  ^wallowed.  There  was  no  thrill  or  murmur  over  it. 
At  the  angle  of  the  right  jaw  a  mass  of  glands,  from  the  size  of  an 
English  walnut  to  that  of  a  pullet's  egg,  somewhat  adherent  to  the 
surrounding  tissues,  firm,  not  tender.  There  was  no  exophthalmos, 
no  tachycardia,  no  tremor  or  sweating.  Blood  and  urine  negative. 
No  fever.     Pulse  80. 

Discussion. — The  case  is  a  very  unusual  one  from  a  clinical  stand- 
point. Two  tumors  are  present,  one  occupying  the  ordinary  site 
of  the  thyroid  gland,  the  other,  at  the  angle  of  the  jaw,  being  appar- 
ently separate.  There  are  none  of  the  toxic  manifestations  of  Graves' 
disease,  yet  the  patient  is  obviously  much  sicker  than  most  of  those 
in  which  what  is  called  a  simple  goiter  or  enlargement  of  the  thyroid 
gland  is  recognized. 

The  patient  is  very  young  for  malignant  disease,  yet  the  gland 
at  the  angle  of  the  jaw  suggests  metastasis.  Possibly  he  has  two  inde- 
pendent diseases,  a  thyroid  tumor  of  some  kind  or  an  adenitis,  s>^h- 
ihtic,  tuberculous,  or  septic  in  t5Ape.  The  characteristics  of  the  cervical 
gland,  however,  are  not  those  ordinarily  seen  in  any  of  these  forms  of 
adenitis. 

As  usual  in  cases  of  doubt,  the  excision  of  a  gland  is  the  obvious 
indication. 

Outcome.— One  of  the  glands  was  removed  and  examined  by 


380  DIFFERENTIAL  DIAGNOSIS 

Dr.  Wright,  who  found  carcinoma.  The  tumor  involving  the  thyroid 
was  then  removed.  The  larynx  was  found  to  be  pushed  to  one  side. 
The  thyroid  tumor  was  also  proved  to  be  cancerous  when  examined 
by  Dr.  W.  F.  Whitney.  The  patient  made  a  good  recovery  and  left 
the  hospital  March  20,  191 1. 

He  returned  to  the  wards  December  26,  191 1,  having  been  treated 
regularly  in  the  Out-patient  Department  in  the  meantime.  Various 
cancer  fluids  had  been  injected  without  relief  and  his  dif^culty  in 
breathing  had  become  steadily  worse.  Dr.  Coolidge  suggested  a 
deep  tracheotomy.  WTiile  being  etherized  the  patient  stopped 
breathing.  Immediate  incision  into  the  cancer,  over  the  windpipe, 
was  followed  by  profuse  bleeding  which  could  not  be  controlled. 
The  trachea  was  opened  in  the  midst  of  the  blood,  with  immediate 
cessation  of  part  of  the  bleeding,  but  there  was  inhalation  of  some  of 
the  blood.  A  tracheal  tube  was  inserted  and  the  patient  began  to 
breathe.  By  the  i6th  of  January  he  was  breathing  easily  through 
the  tube,  which  had,  however,  to  be  adjusted  twice  a  day.  He  was 
then  discharged  to  the  Long  Island  Municipal  Hospital. 

The  patient  remained  at  this  hospital  for  some  months,  and  then 
was  discharged  at  his  own  request,  against  advice.  Nothing  new 
was  ascertained.  A  letter  was  sent  to  him,  March  27,  1913,  and  was 
returned,  marked  "Dead." 

Case  153 

A  night-watchman  of  forty-two  entered  the  hospital  October  28, 
1909.  Five  years  ago  the  patient  noticed  a  small  swelling,  the  size 
of  a  hazelnut,  near  the  back  of  his  neck.  It  was  painless  and  very 
hard.  Soon  after  two  similar  lumps  appeared  in  the  neck  and  were 
removed.  A  month  later  the  side  of  the  neck  began  to  swell  slowly, 
its  size  varying  a  good  deal  from  time  to  time.  There  was  still  abso- 
lutely no  pain.  A  year  later  he  had  the  lump  removed.  It  recurred 
in  a  month  and  was  removed  again  a  month  ago.  Since  the  last  opera- 
tion he  has  had  a  slight  pain  in  his  neck,  but  he  still  complains  of  noth- 
ing except  that  the  growth  recurs.  Since  the  last  operation  he  has 
lost  a  good  deal  of  weight,  he  cannot  say  exactly  how  much.  His 
appetite  is  good  and  he  sleeps  well. 

Physical  examination  shows  good  nutrition  and  color.  Right 
pupil  larger  than  the  left,  both  reacting  normally.  All  other  reflexes 
normal.  On  the  left  side  of  the  neck,  extending  from  the  ear  to  the 
clavicle  and  from  the  median  line  in  the  back  to  the  sternomastoid 
muscle  in  front,  is  a  firm,  insensitive,  fixed  mass,  about  the  size  of 


GLANDS  381 

two  fists,  -w^th  firm,  discrete  nodules,  from  the  size  of  a  pea  to  that  of 
a  bean,  along  its  edge.  A  tongue  of  similar  tissue  extends  under  the 
chin  to  join  a  similar  mass  on  the  right  side  of  the  neck,  about  one- 
half  the  size  of  that  on  the  left.  In  the  left  axilla  a  mass  about  the 
size  of  a  hen's  egg  is  palpable,  but  the  right  axilla  is  free,  and  there  is 
nothing  in  the  groins  or  epitrochlear  regions.  The  chest  and  ab- 
domen are  negative.  Blood  and  urine  negative.  Xo  fever  in  two 
weeks'  observ'ation. 

Discussion. — The  most  important  point  about  this  case  is  that  the 
glands  (if  glands  they  be)  have  been  present  for  five  years  in  the 
postcer\-ical  region  and  have  returned  and  increased,  despite  re- 
moval. There  are  only  two  tj-pes  of  glandular  enlargement  which 
behave  in  this  way,  the  Ij-mphoblastoma  and  the  tuberculous  gland. 
Nothing  else. is  so  chronic. 

Against  the  diagnosis  of  tuberculosis  is  the  fact  that  there  has 
been  no  softening  or  suppuration  in  the  glands,  although  they  have 
been  enlarged  for  five  years.  Further  than  that  they  do  not  involve 
the  skin.  Under  these  conditions  the  diagnosis  of  hmphoblastoma 
is  strongly  probable.  It  is  notable  that  we  have  a  similar  glandular 
enlargement  in  one  axilla  onl}-  and  none  at  all  in  the  groins.  The  old 
idea  that  glandular  growths  of  the  chronic  t}^e  (Hodgkin's  disease) 
were  always  generalized  or  spread  over  many  parts  of  the  body  is 
being  gradually  abandoned,  as  the  result  of  histologic  examinations 
which  show  that  we  may  have  a  h-mphoblastoma  either  of  the  slow- 
growing,  hard,  scirrhous  t\"pe  or  of  the  more  rapid  and  progressive 
form,  yet  remaining  confined  to  a  single  group  of  glands. 

Outcome. — A  gland  was  removed  for  microscopic  examination 
by  Dr.  J.  H.  Wright,  who  reported  that  it  consisted  of  lymphadenoid 
tissue,  but  differed  from  a  normal  hTQph-gland  in  ha\"ing  fewer  sinuses 
and  in  not  possessing  the  definite  architecture  of  the  h-mphatic  gland. 
The  patient  left  the  hospital  on  the  8th  of  November. 

Case  154 

A  junk  dealer  of  forty-eight,  bom  in  Russia,  entered  the  hospital 
'Slay  16.  1910.  Eight  weeks  ago  the  patient  began  to  feel  weak.  Five 
weeks- ago  he  "'caught  cold."  Two  and  a  haK  weeks  ago  he  noticed 
a  sore  on  his  left  forearm  with  severe  pain  there ;  also  pain  in  the  right 
side  of  the  head  and  deep  in  the  right  eye.  Since  the  trouble  began 
he  cannot  see  with  the  right  eye.  There  is  also  pain  in  the  left  shoulder, 
going  down  the  outer  side  of  his  arm.  and  associated  with  weakness 
of  the  arm.     The  httle  finger  and  ring  finger  are  ahnost  useless.     The 


382  DIFFERENTIAL   DIAGNOSIS 

headache  is  associated  with  dizziness,  which  makes  him  unable  to 
work.  There  has  been  no  vomiting  and  no  known  fever.  His  past 
history  is  negative,  save  that  he  takes  one  or  two  glasses  of  whisky 
and  two  or  three  of  wine  a  day.     His  wife  has  had  no  miscarriage. 

Physical  examination  shows  good  nutrition.  The  right  eye  is 
blind  and  the  right  pupil  is  larger  than  the  left;  both  pupils  irregular 
and  reacting  sluggishly.  The  right  abducens  is  paralyzed.  Reflexes 
normal.  Over  the  ulnar  side  of  the  left  forearm  are  numerous  rounded 
white  scars,  and  others  of  the  same  character  are  seen  on  the  inner  side 
of  the  knees.  On  the  radial  side  of  the  left  forearm,  at  the  junction  of 
the  lower  and  middle  third,  is  a  thickened,  raised,  reddish-brown  crust, 
I  by  i|  cm.,  surrounded  by  a  red  infiltrated  area,  5  cm.  in  diameter. 

At  the  junction  of  the  first  right  rib  with  the  manubrium  is  a  firm, 
oval  tumor,  4  by  3  cm.,  i|  cm.  high,  cartilaginous  in  feel,  and  slightly 
tender.  A  sHght  rachitic  rosary  is  palpable  on  both  sides.  Under  the 
angle  of  the  right  jaw  is  a  large  tender  lymph-node,  many  bean-sized 
glands  in  the  axillae  and  groins.  The  epitrochlears  are  palpable. 
Chest  and  abdomen  are  negative.  Wassermann  reaction  negative. 
Urine  negative.  White  cells,  24,000;  hemoglobin,  70  per  cent.  Differ- 
ential count  of  200  white  cells  shows  polynuclears,  7  per  cent.;  small 
lymphocytes,  4  per  cent.;  large  mononuclear  cells  with  "azure" 
granules,  89  per  cent.  The  fundus  of  the  right  eye  shows  two  hemor- 
rhages near  the  disk. 

The  condition  of  the  eye  and  the  skin  lesions  suggest  syphilis. 
Further  examination  of  the  left  arm  showed  that  there  were  irregular 
areas  of  anesthesia  and  no  power  to  extend  the  forearm. 

Discussion. — The  symptoms  are  curiously  scattered  and  various. 
First  an  intracranial  group,  with  troubles  in  the  arm,  pain,  paralysis, 
and  soreness.  The  particular  localization  of  these  is  unlike  that  of 
peripheral  neuritis  or  any  other  peripheral  disease,  and  suggests 
trouble  in  the  brain.  The  condition  of  the  pupils  and  the  paralysis 
of  one  eye  muscle  suggests  the  same  thing.  The  scars  and  the  infil- 
tration upon  the  arm,  when  considered  in  connection  with  the  ocular 
lesions',  lead  us  to  surmise  that  the  intracranial  lesions  may  be  syph- 
ilitic. 

But  the  tumor  on  the  rib  and  the  glandular  enlargements  of  the 
neck,  axillae,  and  groins  draw  our  attention  in  another  direction.  The 
rib  tumor  might  well  be  a  myeloma,  a  metastasis  from  hypernephroma, 
or  possibly  a  bony  or  cartilaginous  outgrowth.  The  remains  of  a 
rachitic  rosary  suggest  still  another  possibility  that  the  rib  tumor 
might  be  rachitic. 


GLANDS  383 

All  these  doubts  are  settled  by  the  blood  examination  which 
is  characteristic  of  lymphoid  leukemia,  that  is,  of  the  type  of  lympho- 
blastoma associated  with  a  multiplication  of  tumor  cells  in  the  blood ; 
in  other  words,  with  lymphemia.  Note  the  very  moderate  increase 
in  the  total  number  of  white  cells.  This  is  what  we  should  expect  in 
a  case  of  this  sort.  The  counts  of  100,000  or  more  per  cubic  milli- 
meter are  usually  in  the  myeloid  type  of  leukemia.  The  greater 
number  of  the  lymphoid  cases,  during  most  of  their  course,  have  a 
leukocyte  count  of  40,000  or  less. 

At  the  time  of  the  patient's  second  hospital  visit  the  chnical 
picture  was  still  clearer.  Fever  and  more  infiltrating  nodules  had 
now  appeared  and  the  growth  had  doubtless  involved  the  marrow, 
crowding  out  the  erythroblastic  centers  and  producing  an  anemia  of 
the  type  knqwn  as  myelophthisic  anemia,  that  is,  where  the  red 
cells  of  the  marrow  are  starved  out,  pushed  to  the  wall — the  bony 
wall  of  the  marrow — and  gradually  exterminated.  This  is  the  ordinary 
type  of  anemia  occurring  in  the  course  of  a  lymphoblastoma  or  myelo- 
blastoma of  the  leukemic  type. 

A  nodule  was  excised  from  the  axilla  and  examined  by  Dr.  J.  H. 
Wright,  showing  a  lymph-gland,  very  rich  in  the  larger  lymphocytes 
and  continuous  with  a  mass  of  connective  tissue  and  fat  tissue,  more 
or  less  densely  infiltrated  with  large  lymphocytes,  associated  with 
some  eosinophils  and  myelocytes  and  a  few  small  lymphocytes. 
Diagnosis,  malignant  lymphoma  or  leukemic  tumor. 

The  patient  left  the  hospital  on  the  19th  of  May  and  returned  on 
the  27th.  Since  leaving  the  hospital  he  has  had  constant  headaches, 
very  severe  and  confined  to  the  right  side  of  the  head.  He  has  now 
no  pain  in  the  left  arm,  but  much  in  the  left  shoulder.  His  right  eye 
is  still  blind,  the  left  normal.  Since  he  left  the  hospital  his  right  ear 
has  become  deaf  and  "roars  like  an  engine."  He  has  been  in  bed  since 
he  left  the  hospital  because  of  fatigue;  increased  pain  in  the  shoulder 
seizes  him  as  soon  as  he  stands  up,  and  is  accompanied  by  an  uncon- 
trollable desire  to  defecate. 

Physical  examination  showed  at  this  time  a  freely  movable  Ijrmph- 
node  over  the  middle  of  the  right  clavicle.  The  epitrochlears  were 
of  the  size  of  a  lentil.  By  percussion  the  spleen  measured  8  by  10  cm., 
but  its  edge  could  not  be  felt.  The  entire  left  arm  was  now  atrophic 
and  the  deltoid  group  of  muscles  soft  and  flabby.  The  crust,  pre- 
viously described,  was  still  present,  also  the  tumor  near  the  breast  bone. 

The  red  cells  at  this  time  numbered  1,780,000,  and  the  white, 
37,000.     Differential  count  was  practically  as  before.     During  the 


384 


DIFFERENTIAL  DIAGNOSIS 


two  weeks  of  his  stay  in  the  hospital  the  red  count  steadily  declined 
until  it  reached  976,000,  with  30  per  cent,  hemoglobin,  on  the  6th 

of  June.  The  leukocyte  count  also  de- 
clined from  37,000  at  entrance  to  14,000 
June  I,  and  13,000  June  6.  The  dif- 
ferential count,  however,  did  not  change 
in  any  important  respect.  The  red  cells 
showed  slight  achromia  and  abnormal 
staining,  with  considerable  variations 
in  size  and  shape.  The  patient  ran  a 
continuous  fever,  as  shown  in  Fig.  132. 
The  urine  was  negative.  Examination 
of  the  ears  by  Dr.  H.  P.  Mosher  showed 
a  moderate  diminution  of  hearing  in 
each  ear,  apparently  due  to  middle-ear 
catarrh.  Tests  for  involvement  of  the 
labyrinth  were  negative. 

On  the  5  th  of  June  there  was  evi- 
dence of  involvement  of  the  mastoid, 
and  purulent  discharge  from  the  ear 
began  the  ist  of  June.  Coincident  with 
the  appearance  of  this  suppuration  occurred  the  fall  of  white  cor- 
puscles mentioned  before.  The  patient  lost  ground  steadily,  and 
died  on  the  7th  of  June.     Autopsy  showed  lymphoid  leukemia. 


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Case  155 

A  gardener  of  fifty  entered  the  hospital  August  22,  19 10.  The 
patient  has  been  well  until  the  present  illness;  he  denies  venereal 
disease  and  has  a  negative  family  history.  Three  weeks  ago  he 
noticed  a  small  lump  in  his  neck  and  others  in  both  axillae  and  groins. 
They  were  then  about  half  their  present  size.  He  feels  perfectly  well, 
except  that  he  gets  fatigued  more  easily  than  before.  He  has  lost  no 
weight.     He  has  a  good  appetite  and  sleeps  well. 

Physical  examination  shows  good  nutrition,  pupils  slightly  irreg- 
ular in  shape,  equal  in  size,  and  reacting  normally.  Tonsils  are  very 
large.  All  the  superficial  lymph-nodes,  including  the  epitrochlear, 
mental,  submaxillary,  and  occipital,  are  enlarged.  They  vary  from 
the  size  of  a  pea  to  that  of  a  walnut,  are  freely  movable,  and  not 
tender.  The  axillary  glands  extend  along  the  pectoral  muscle  toward 
the  nipple.  Chest  and  abdomen  negative,  except  that  the  sharp, 
firm,  painless  edge  of  the  spleen  can  be  felt  on  deep  inspiration. 


GLANDS 


385 


Wassermann  reaction  is  positive.  Blood-pressure,  140  mm.  Hg. 
Urine  negative.  Blood  examination  shows  red  cells,  5,900,000; 
hemoglobin,  80  to  90  per  cent.  In  stained  smears  the  red  cells  are 
normal.  The  course  of  the  white  cells  is  seen  in  Fig.  133.  The  per- 
centage of  polynuclear  cells  is  from  5  to  25  per  cent.,  the  rest  of  the 


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Fig.  133. — Chart  of  white  cells  in  Case  155. 

white  cells  being  of  the  lymphocytic  type.  The  small  lymphocytes 
markedly  predominate  and  make  up  from  55  to  66  per  cent,  of  all  the 
white  cells  present.     The  fundus  oculi  is  normal. 

Discussion.— The  patient  feels  so  well  that  it  is  difficult  to  believe 
that  he  has  any  serious  disease,  yet,  with  three  sets  of  enlarged  glands, 

Vol.  11—25 


386  DIFFERENTIAL  DIAGNOSIS 

he  certainly  is  far  from  well.  The  positive  Wassermann  reaction, 
in  connection  with  the  generalized  adenitis,  might  lead  us  to  assume 
that  the  latter  was  of  syphilitic  origin,  but  no  one,  I  suppose,  would 
undertake  to  rnake  a  diagnosis  in  such  a  case  without  counting  the 
white  corpuscles,  and  if  this  were  done  there  could  be  no  further 
doubt  regarding  the  diagnosis  of  the  case.  It  is  clearly  one  of  lym- 
phemia  with  lymphoblastoma. 

Outcome. — Under  x-ray  treatment  the  glands  diminished  in  size. 
The  health  of  the  patient  seemed  to  be  perfect,  and  after  the  loth  of 
September  he  preferred  to  continue  treatment  in  the  Out-patient  De- 
partment and  was  accordingly  discharged,  having  gained  3  pounds 
since  entrance. 

Case  156 

A  carpenter  of  forty  entered  the  hospital  October  3,  1910.  The 
patient's  father  died  at  sixty-five  of  unknown  cause;  his  mother,  of 
cancer  of  the  breast;  one  cousin,  of  tuberculosis.  Four  brothers  and 
one  sister  are  living  and  well.  The  patient's  wife  has  had  two  or  three 
miscarriages,  and  is  said  to  have  had  a  sore  throat,  possibly  of  syph- 
ilitic origin.  The  last  child,  just  born,  seems  healthy.  The  patient 
was  always  well  until  June,  1909,  when  he  was  in  the  Natick  Hospital 
and  an  operation  was  done  upon  his  left  foot.  The  diagnosis  was  "os- 
teitis, possibly  malignant."  July  27th  he  was  at  the  Carney  Hospital, 
and  Dr.  Macausland  removed  a  tumor  from  his  left  foot  which  was 
said  to  be  mixed  sarcoma  and  carcinoma,  but  no  pathologic  report 
could  be  found.  After  that  he  seemed  to  be  fairly  well  until  two  or 
three  months  ago,  when  he  began  to  be  very  nervous  and  restless, 
frequently  rubbing  different  parts  of  his  body,  bathing  his  feet  to 
allay  itching,  complaining  of  vague  abdominal  discomforts  and  belch- 
ing. Some  deafness  in  one  ear  was  noticed  ten  days  ago.  This  morn- 
ing he  seemed  to  be  completely  deaf  in  both  ears.  His  bowels  are  very 
constipated.     Nothing  else  can  be  ascertained  about  his  history. 

Physical  examination  showed  good  nutrition,  dry,  harsh  skin, 
the  right  pupil  larger  than  the  left,  both  reacting  normally.  The 
tongue  showed  a  very  thick,  brown  coat.  Superficial  lymph-glands 
not  enlarged.  Chest  and  abdomen  negative.  Knee-jerks  not  ob- 
tained. Achilles'  jerk  not  obtained.  In  the  left  groin  are  a  few 
confluent  glands,  making  up  a  mass  the  size  of  two  walnuts.  The  left 
knee  is  somewhat  smaller  than  the  right.  On  the  outer  side  of  the  left 
foot,  near  the  ankle  bone,  are  a  depressed  scar  and  some  red  sub- 
cutaneous lumps,   free  from   tenderness.     The  blood   shows  leuko- 


GLANDS  387 

cytes  varying  from  12,000  to  16,000,  with  79  per  cent,  polynuclear 
cells.     Urine  negative. 

During  the  month  of  his  stay  in  the  ward  his  temperature  ranged 
usually  between  99°  and  100 "^  F.;  his  pulse  between  no  and  130; 
respiration  about  25.  The  feces  were  negative  for  guaiac  on  three 
occasions.  Sputum  showed  no  prevailing  type  of  organism.  Ex- 
amination of  the  ears  by  Dr.  H.  P.  Mosher  showed  acute  double 
labyrinthitis,  probably  specific.  The  fundus  oculi  was  normal. 
A  neurologic  consultant  could  throw  no  light  upon  the  case,  though 
the  patient  had  a  well-marked  Romberg  sign,  poor  co-ordination  in 
the  arms,  dull  and  delayed  sensation  in  the  legs.  There  was  much 
twitching  of  the  muscles  of  the  arms,  with  scratching  and  restlessness. 
October  7th  the  right  pupil  reacted  poorly. 

October  7th,  5  c.c.  of  clear  fluid  were  withdrawn  from  the  spinal 
canal.  Cell  count,  i  per  centimeter.  Stained  smear  showed  polynuclear 
cells,  66  per  cent.;  lymphocytes,  32  per  cent.;  eosinophils,  2  per  cent., 
and  many  red  cells;  in  other  words,  probably  an  admixture  of  blood. 

Discussion. — The  s5Aphilitic  history,  the  absence  of  tendon  re- 
flexes, the  condition  of  the  pupils,  and  the  deafness  may  well  be 
symptoms  of  syphihs.  On  the  other  hand,  the  presence  of  the  lumps 
upon  the  foot  and  in  the  groin  and  the  curious  restlessness  suggest  a 
possible  brain  metastasis  from  neoplasm.  Possibly  he  has  more  than 
one  disease.  It  seems  very  difficult  to  reconcile  or  organize  under 
one  diagnosis  all  the  facts  given.  As  a  matter  of  fact,  until  the 
histologic  examination  of  the  excised  gland  (see  below)-  was  made, 
no  satisfactory  diagnosis  was  arrived  at  in  this  case  during  life,  al- 
though we  had  very  little  doubt  that  syphilis  accounted  for  at  least 
a  part  of  his  troubles. 

Outcome. — On  the  8th  of  October  the  glandular  mass  in  the  left 
groin  was  excised.  Microscopic  examination  by  Dr.  J.  H.  Wright 
showed  malignant  lymphoma.  No  diagnosis  could  be  made,  and  the 
patient  remained  in  the  ward  without  change  until  the  latter  part  of 
October,  when  he  became  incontinent  and  delirious  at  night.  On  the 
23d  he  had  convulsive  twitching  and  jerking  of  the  arms  and  legs  for 
a  couple  of  days.  At  this  time  the  reflexes  could  not  be  obtained. 
November  3d  the  patient  died.  The  clinical  diagnosis  was  malignant 
disease  of  the  foot  and  inguinal  glands,  with  metastases  in  the  central 
nervous  system,  possibly  also  syphihs  and  tabes.  Myxedema  was 
also  considered.  Autopsy  No.  2713  showed  no  sufficient  cause  for 
death.  There  was  a  sjrphihtic  aortitis,  a  small  hypernephroma  of  the 
kidney,  and  hemorrhagic  areas  in  the  lungs. 


388  DIFFERENTIAL  DIAGNOSIS 

Case  157 

A  teacher  of  thirty-five  entered  the  hospital  December  28,  1910. 
Her  family  history  was  negative.  She  has  been  subject  to  colds  and 
tonsillitis  in  the  past  and  has  had  a  slight  dry  cough  for  a  year.  She 
has  had  "bronchitis"  every  one  or  two  years. 

In  the  summer  of  1909  she  was  at  Rutland,  with  constant  low 
fever,  and  an  eruption  which  started  in  the  ears  and  nose  and  gradu- 
ally covered  the  lower  part  of  face.  There  was  a  free  discharge  of  pus 
from  it  and  some  blood.  This  began  to  go  three  months  ago  and  has 
now  nearly  ceased.     Her  menstruation  is  regular  and  habits  good. 

In  September,  1909,  she  noticed  "glands"  on  each  side  of  her 
neck.  They  were  largest  in  January,  1910,  and  have  been  smaller 
since,  but  others  have  appeared  behind  the  left  ear  and  in  the  right 
axilla.  In  January,  1910,  she  was  in  bed  six  weeks  with  "heavy  grip 
cold"  and  epigastric  pain.  She  had  a  similar  attack  in  March,  1909. 
After  it  the  left  leg  was  lame  and  the  foot  was  painful  and  had  purple 
spots  on  it.  She  has  not  walked  since  January.  In  June,  19 10,  she 
wakened  one  morning  to  find  her  left  hand  and  left  leg  useless  and  the 
right  side  of  her  face  "drawn  down."  Her  speech  was  poor.  She  has 
gradually  improved  since,  but  the  left  hand  is  still  weak. 

She  has  not  worked  since  March,  1909.  There  has  been  no  loss 
of  weight  and  no  pain.  Her  appetite  is  fair.  The  bowels  are  costive; 
sleep  is  good. 

Physical  examination  is  negative  except  for  hard,  matted,  non- 
tender,  large  pea-sized  glands  over  the  left  clavicle  and  larger  ones  in 
the  right  neck  and  axilla. 

There  is  edema  in  the  left  leg  and  foot  and  the  calf  is  sHghtly 
tender.  There  is  ankle-clonus  (four  to  five  oscillations)  on  the  left. 
The  left-hand  grip  is  weaker.  The  blood  and  urine  are  negative ;  blood- 
pressure,  115  mm.  Hg.;  Wassermann  negative.  There  is  no  fever  in 
one  week. 

Discussion. — Despite  the  negative  Wassermann  reaction  there  is  a 
good  deal  to  suggest  syphilis  as  a  cause  of  the  adenitis  in  this  case. 
The  attack  of  June,  1910,  might  well  be  the  result  of  syphiHtic  vascular 
lesions  in  the  brain.  The  presence  of  ankle-clonus  and  muscular  weak- 
ness upon  the  left  side,  six  months  later,  gives  support  to  the  idea 
that  some  organic  cerebral  lesion  is  present. 

There  is  good  reason  for  referring  the  glands  to  the  lympho- 
matous  or  lymphoblastic  group  and  there  is  no  evidence  of  tubercu- 
losis. 


GLANDS  389 

The  fact  that  glandular  enlargement  was  noticed  immediately 
after  the  purulent  cutaneous  lesions  of  the  summer  of  1909  renders  it 
barely  possible  that  a  septicemia,  with  glandular  hypertrophy  in 
response  to  it,  may  be  at  the  root  of  her  troubles.  Such  a  septicemia, 
producing  not  only  local  but  general  glandular  enlargement,  is  not 
infrequently  seen  in  the  form  beginning  with  tonsillitis  and  associated 
with  streptococci. 

Outcome. — April  11,  19 13,  Dr.  James  L.  Wheaton,  Jr.,  of  Paw- 
tucket,  R.  I.,  the  patient's  family  physician,  writes  as  follows:  After 
leaving  the  Massachusetts  General  Hospital  the  patient  was  given 
x-ray  treatment  to  the  glands,  as  recommended  there.  She  grew 
progressively  worse  and  the  glands  in  the  neck  enlarged.  In  every 
way  she  appeared  to  be  nearing  the  end,  which  was  predicted  when 
she  was  at  the  hospital.  She  has  had  a  good  deal  of  facial  acne,  and 
in  the  attempt  to  clear  this  up  a  staphylococcic  vaccine  was  given, 
and,  "much  to  my  surprise,  not  only  did  the  acne  improve,  but  the 
glands  began  to  diminish  in  size  and  her  strength  gradually  returned. 
Ever  since  that  time  I  have  given  her  regular  doses  of  staphylococcic 
vaccine.  She  has  regained  her  weight  and  most  of  her  strength. 
The  glands  have  almost  disappeared,  and  it  seems  as  if  she  was  to  be 
well  again." 

The  diagnosis  of  Hodgkin's  disease  or  lymphoblastoma  was  that 
thought  the  most  probable  when  she  left  the  hospital,  but,  in  view 
of  the  above  information,  this  seems  to  be  very  improbable.  An 
adenitis  of  the  septic  t3^e  seems  the  most  reasonable  diagnosis. 

Case  158 

A  cook  of  forty-one,  a  Swede,  entered  the  hospital  November  22, 
1910,  on  account  of  frequent  attacks  of  tonsilHtis  and  enlarged  tonsils. 
On  the  23d  the  tonsils  were  removed,  also  the  adenoids.  The  patient 
left  the  hospital  the  same  day.  December  20th,  1910,  the  patient 
came  into  the  hospital  again,  stating  that  since  last  July  he  had  been 
bothered  by  stiffness  and  pain  in  the  lower  back,  increased  by  quick 
motion  or  Hfting.  For  the  last  eight  weeks,  in  addition  to  this  pain, 
he  has  had  soreness  and  stiffness  in  the  right  shoulder  and  elbow. 
Since  his  operation  of  three  weeks  ago  he  has  had  a  painful  swelling 
in  the  glands  of  his  neck.  He  has  no  cough,  but  raises  a  good  deal  of 
matter  from  his  throat.  For  years  he  has  always  had  some  shortness 
of  breath  on  exertion  and  occasional  attacks  of  pain  in  the  left  axilla. 
He  uses  ^  pint  of  whisky  a  day,  but  has  never  lost  a  day's  work  on 
account  of  liquor.     His  family  history  is  negative,  his  appetite  has 


39°  DIFFERENTIAL  DIAGNOSIS 

been  good,  but  he  has  lost  markedly  in  weight.     Eight  years  ago  he 
weighed  172  pounds;  a  year  ago,  154  pounds;  now,  127  pounds. 

Physical  examination  showed  fair  nutrition.  Normal  pupils  and 
reflexes.  Throat  slightly  reddened,  but  usually  no  exudate.  In  the 
right  side  of  the  neck  were  tender,  matted  masses  of  glands;  many 
similar  glands  about  the  size  of  a  pea  below  this.  Axillary,  inguinal, 
and  cpitrochlcar  nodes  were  palpable,  but  not  abnormal.  Chest  and 
abdomen  negative.  There  was  some  tenderness  and  pain  about  the 
left  scapula  and  right  sacro-iliac  joint.  Urine  negative.  The  blood 
showed  a  slight  polynuclear  leukocytosis,  ranging  from   11,000  to 


Fig.  134. — Condition  of  liver  and  glands  in  Case  158 

19,000,  Dr.  Osgood  considered  the  condition  of  the  back  an  infec- 
tious arthritis.  On  the  14th  of  January  the  conditions  were  as  shown 
in  Fig.  134. 

Discussion. — This  history  reveals  an  alcoholic,  with  enlarged 
cervical  glands,  following  a  tonsil  operation,  with  pain  rather  widely 
distributed  in  the  trunk  and  right  arm,  with  marked  loss  of  weight, 
dyspnea,  and  anginoid  paroxysms. 

The  physical  examination  shows,  besides  the  cervical  mass,  an 


GLANDS  391 

enlarged  liver,  the  surface  of  which  is  so  uneven  that  only  three  possi- 
bilities need  to  be  considered— malignant  disease,  syphiUs,  and 
hydatid.  We  have  nothing  in  the  patient's  history  nor  in  his  blood 
to  support  the  theory  of  hydatid,  and  his  marked  loss  of  weight  and 
severe  general  discomfort  is  not  what  one  expects  in  patients  suffer- 
ing from  hydatid  disease.  As  a  rule,  such  patients  complain  of  very 
little,  but  we  need  an  explanation  of  the  lump  below  the  ribs.  This 
patient  does  not  want  explanation,  but  relief. 

Syphihs  cannot  be  excluded,  but  we  have  no  positive  evidence  of 
it.     Malignant  disease  is  probable. 

Outcome. — One  of  the  glands  was  excised  and  examined  by  Dr. 
J.  H.  Wright,  who  found  it  to  be  a  metastatic  malignant  tumor,  the 
nature  of  which  he  could  not  at  first  determine.  January  15th  a 
red  patch  appeared  on  the  right  cheek,  which  was  pronounced  "erysip- 
elas" by  a  skin  consultant.  The  patient  lost  ground  rapidly,  and  died 
on  the  30th  of  January.  Autopsy  No.  2785  showed  a  neuroblastoma 
of  the  neck,  pleura,  liver,  retroperitoneal  and  bronchial  lymph-nodes; 
tuberculosis  of  a  bronchial  lymphatic  gland,  chronic  perisplenitis, 
hydrothorax. 

Case  159 

A  farmer  of  thirty-six  entered  the  hospital  January  2,  191 1. 
In  the  fall  of  1909  he  was  laid  up  four  days  with  an  attack  of  nausea 
and  vomiting  without  assignable  cause.  Before  this  he  had  always 
been  well.  Family  history  excellent.  His  next  attack  was  from  the 
spring  of  1910  to  the  3d  of  July,  1910.  Since  then  he  has  had  an 
attack  about  every  third  week,  lasting  three  or  four  days  at  a  time. 
The  vomitus  is  brown  and  never  contains  blood.  His  stomach  has 
been  washed  out  a  number  of  times  without  any  special  benefit  in  the 
way  of  information  or  improvement.  His  last  attack  was  December 
15th.  His  appetite,  bowels,  and  sleep  are  good  and  he  feels  perfectly 
well.  He  loses  about  10  pounds  with  each  attack,  but  quickly  regains 
it.  He  has  never  had  anything  Hke  hghtning  pains  or  other  sensory 
symptoms. 

Physical  examination  shows  normal  pupils,  glands,  and  reflexes, 
and  is  in  other  respects  wholly  negative,  save  for  a  rapid  pulse  and  a 
slight  excess  of  blood-pressure  (Fig.  135).  Blood  and  urine  were 
normal.  Weight,.  119  pounds,  stripped.  Wassermann  reaction  nega- 
tive. Dr.  J.  J.  Putnam  found  no  lesions  of  the  central  nervous  system. 
Examination  of  the  eyes  was  negative,  as  was  examination  of  the  ears. 
There  was  a  very  slight  enlargement  of  the  thyroid.     The  edge  of 


392 


DIFFERENTIAL  DIAGNOSIS 


the  liver,  firm,  smooth,  not  tender,  was  felt  2  inches  below  the  ribs 
on  the  3d  of  January.  There  was  a  very  slight,  fine  tremor  of  the 
fingers.  No  bulging  of  the  eyes,  no  sweating.  The  patient  had  no 
s}Tnptoms  during  his  week  in  the  hospital  and  left  on  the  7  th  of 
January. 

On  the  28th  of  March,  191 3,  he  writes  that  his  vomiting  spells  have 
been  coming  somewhat  more  frequently  during  the  past  two  years. 
They  are  not  accompanied  by  pain,  and  he  recovers  very  rapidly  from 
them.  He  states  that  the  nerves  of  his  stomach  are  stronger,  but  that 
his  throat  seems  to  be  swelling  and  that  he  has  some  spells  of  choking. 

Discussion. — The  periodic  spells  of  vomiting 
are  like  those  often  seen  in  tabes,  but  there  is 
nothing  else  in  the  case  to  suggest  this,  and  the 
important  points  in  the  physical  examination 
are  the  palpable  liver,  the  slight  enlargement 
of  the  thyroid,  the  tremor,  and  the  rather  high 
blood-pressure.  I  have  never  known  such  vom- 
iting spells  as  this  to  result  from  a  thyroid  in- 
toxication. Vomiting  may  form  a  part  of  such 
intoxication,  but  only  in  patients  whose  other 
toxic  symptoms  are  much  more  marked.  It 
seems  to  me  very  doubtful  whether  the  thyroid 
has  anything  to  do  with  this  patient's  vomiting. 
Outcome. — The  patient  was  seen  again  April 
23,  1913.  He  stated  that  his  vomiting  spells 
now  lasted  only  part  of  a  day  instead  of  two 
or  three  days,  as  formerly.  This  time  he  men- 
tioned that  during  the  previous  year  he  had 
had  four  spells  of  pain  in  the  legs,  each  attack 
lasting  for  a  whole  night,  and  darting,  as  he 
says,  like  a  pleurisy,  which,  to  him,  means  very 
quickly.  Although  the  pain,  as  he  says,  darts, 
it  is  yet  confined  to  one  spot,  and  in  each  at- 
tack this  spot  has  been  somewhere  between  the 
knee  and  the  ankle.  During  the  past  six  months 
his  vomiting  attacks  have  come  every  other  day,  usually  starting 
about  6.30  A.  M.  There  is  no  nausea  with  the  attacks,  but  he  is  very 
nervous  in  them  and  wants  to  be  alone  in  a  dark  room.  He  has  done 
no  work  for  three  years.  Occasionally  a  drink  of  water  sticks  some- 
where in  his  gullet  and  is  regurgitated.  Food  is  sometimes  regurgitated 
in  the  same  way,  and  after  such  an  attack  he  has  for  some  minutes  a 


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Fig.  135. — Chart  of  Case 
159- 


GLANDS  393 

sense  of  obstruction  in  the  gullet.  The  patient  entered  the  hospital 
again  on  the  23d  of  April,  1913,  stating  that  the  attacks  of  vomiting 
had  gradually  grown  more  frequent.    He  has  lost  5  pounds  in  weight. 

Examination  shows  normal  pupils,  very  lively  knee-jerks  and 
plantar  reflexes,  but  is  otherwise  negative.  Systolic  blood-pressure 
is  156  to  no  mm.  Hg. 

His  lumbar  puncture  fluid  shows  50  cells  per  cubic  millimeter,  all 
of  them  lymphocytes.  Wassermann  reaction  in  this  fluid  is  positive; 
in  the  blood,  negative.  An  x-ray  shows  no  change  in  the  outline  of 
heart  and  aorta,  no  evidence  of  aortitis.  Cerebrospinal  syphilis  with 
gastric  crises  is  evidently  the  diagnosis,  despite  the  normal  pupils 
and  knee-jerks.     The  enlarged  thyroid  is  probably  unimportant. 

Case  160 

A  farmer  of  sixty-five  entered  the  hospital  January  23,  1911. 
The  patient  had  "scrofula"  in  childhood;  that  is,  the  glands  in  the 
neck  were  then  enlarged  and  discharged  for  a  time,  but  have  never 
bothered  him  since  until  three  months  ago,  when  he  noticed  that  on 
the  right  side  of  the  neck  the  glands  were  larger  than  usual.  For 
a  week  they  have  been  painful  and  tender.  The  tonsil  was  removed 
this  morning  in  the  Out-patient  Department  for  diagnosis.  His 
appetite  is  good,  and  he  has  slept  well  until  this  week,  when  the  pain 
has  kept  him  awake.  He  had  worked  until  entrance,  has  no  cough,  no 
fever,  no  loss  of  weight. 

Physical  examination  shows  a  well-nourished,  healthy-looking 
man.  Pupils  and  reflexes  normal.  Under  the  angle  of  the  jaw,  on  the 
right,  is  a  nodular  mass  the  size  of  a  fist.  Elsewhere  the  glands  are 
not  enlarged.  The  right  tonsil  is  about  the  size  of  a  plum  and  is  ab- 
normally red.  Physical  examination  otherwise  negative,  blood  and 
urine  normal,  no  fever  in  ten  days'  observation. 

Discussion. — Apparently  this  patient  had  adenitis  in  his  child- 
hood, perhaps  tuberculous,  but  we  have  no  reason  to  connect  that 
with  his  present  troubles.  The  essentials  in  his  present  clinical  condi- 
tion are  three  months'  complaint  of  cervical  adenitis,  with  one  week  of 
pain  and  tenderness,  in  a  man  of  sixty-five  who  feels  perfectly  well. 
The  physical  examination  adds  nothing  except  on  the  negative  side. 
There  is  no  reason  to  assume  that  the  glands  represent  metastatic 
deposits,  for  there  is  no  disturbance  in  the  function  of  any  thoracic  or 
abdominal  organ.  It  is  not  at  all  probable  that  they  are  tuberculous 
or  syphilitic,  since  neither  of  these  types  of  adenitis  is  apt  to  appear 
in  a  healthy  man  of  sixty-five.     There  is  no  evidence  of  sepsis.     A 


394  DIFFERENTIAL  DIAGNOSIS 

primary  tumor  of  the  gland  itself  is  the  only  plausible  h^'pothesis 
remaining. 

Outcome. — Pieces  were  removed  from  the  tonsil  and  examined  by 
Dr.  W.  F.  Whitney.  Diagnosis  given,  l>Tnphosarcoma.  Dr.  Mau- 
rice H.  Richardson  saw  the  patient  in  consultation  and  advised  no 
operation.  The  Wassermann  reaction  was  negative.  The  patient 
was  given  A:-ray  treatment  and  improved  considerably.  Nevertheless, 
on  February  ist  he  felt  that  he  must  go  home  and  did  so. 

Remarks. — Although  the  diagnosis  of  lymphosarcoma  is  here  re- 
corded, there  is  no  reason  to  believe  that  this  represents  anything  but  a 
variety  in  terminology.  What  we  are  dealing  with  is  that  same  extra- 
ordinary multiple  form  of  disease,  already  several  times  exemplified 
in  this  chapter,  lymphoblastoma.  It  may  be  worth  while  here  to 
indicate  some  of  the  extraordinarily  wide  clinical  differences  which  are 
now  included  under  this  single  term: 

(i)  The  disease  may  be  acute  or  chronic.  It  may  last  forty  or  fifty 
years.  It  may  run  its  course  within  a  few  weeks  and  prove  fatal  within 
a  few  weeks. 

(2)  It  may  be  confined  to  a  single  gland  or  group  of  glands,  either 
inside  the  body  cavities  or  in  the  familiar  external  sites  of  glandular 
enlargement. 

(3)  It  may  or  may  not  be  associated  with  involvement  of  the  spleen, 
the  bone-marrow,  and  the  minute  lymphadenoid  foci  situated  in  the 
skin  and  subcutaneous  tissues  and  elsewhere. 

(4)  It  may  be  associated  with  normal  blood  or  with  lymphemia. 

(5)  The  glands  may  be  few  or  many,  large  or  small,  hard  or  soft. 

Owing  to  its  extraordinary  chronicity  in  certain  cases,  one  hesi- 
tates to  class  it  with  the  malignant  neoplasms,  yet  in  other  cases  no 
known  tumor  is  more  rapidly  fatal  or  invades  more  disastrously  the 
surrounding  parts. 

Case  161 

A  storekeeper  of  forty-eight,  born  in  Russia,  entered  the  hospital 
February  21,  191 1.  A  year  ago  the  patient  began  to  get  weak  and 
could  not  do  his  usual  work.  Three  months  ago  he  noticed  a  lump 
under  the  skin  of  the  right  temple;  two  weeks  later,  another  over  the 
left  eyebrow;  a  fortnight  later,  two  more  in  the  same  region.  After 
this  last  group  appeared,  he  began  to  have  headache  and  noticed 
a  squint,  for  which  he  consulted  an  eye  doctor,  three  months  ago, 
without  benefit.  For  the  last  two  months  he  has  noticed  no  change 
in  the  size  of  the  lumps,  but  his  headache  often  keeps  him  awake. 


GLANDS  395 

It  was  a  good  deal  relieved,  a  week  ago,  by  a  nosebleed.  He  gave 
up  work,  finally,  about  a  month  ago,  though  he  had  not  been  working 
well  for  some  time  before  that.  Eighteen  months  ago  he  weighed 
148  pounds;  seven  months  ago,  135  pounds,  with  clothes;  now,  118 
pounds,  without  clothes. 

Physical  examination  shows  poor  nutrition,  slight  pallor,  five 
tumors  about  the  face,  in  the  positions  indicated  in  Fig.  136.  Number 
I  was  soft,  unattached  to  the  skin,  not  movable  or  tender,  not  fluctuant, 
about  3^  cm.  in  diameter;  No.  2  is  firmer,  otherwise  about  the  same. 
The  others  resemble  No.  2.  The 
left  eyeball  is  somewhat  protu- 
berant and  shows  external  squint. 
The  left  pupil  reacts  very  little 
to  Ught  and  not  at  all  to  distance. 
The  lymph-glands  are  not  re- 
markable. The  heart  is  negative, 
save  for  a  late,  blowing  systolic 
murmur,  transmitted  to  the  axilla 
and  the  whole  precordia.  The 
apex  extends  4  cm.  outside  the 
nipple  line  in  the  fifth  space.  The 
impulse  is   diffuse  and    heaving.      ^.        .     ou     ■  •.•       ^  1 

^  °        Fig.   130. — bhowing  position  01  lumps  in 

At    the    base    hardly    any    first  Case  161. 

sound  is  audible.     The  pulmonic 

second  is  accentuated.      Blood-pressure,  135  mm.  Hg.,  systolic;  80 

mm.  Hg.,  diastolic.     The  lungs  are  negative. 

The  abdomen  is  negative  except  for  a  deeply,  felt  sharp  edge,  cor- 
responding to  the  spleen,  and  a  similar  edge,  probably  the  Hver;  both 
of  these  edges  about  2  inches  below  the  ribs.  There  was  no  tempera- 
ture in  ten  days'  observation.  The  urine  was  not  remarkable,  save 
for  the  presence  of  the  Bence-Jones  body.  The  blood  showed  red 
cells,  2,100,000;  white  cells,  7500;  hemoglobin,  75  per  cent.  Differ- 
ential count  not  remarkable.  Stained  smear  shows  a  few  abnormally 
stained  or  stippled  red  cells,  moderate  achromia,  and  deformities  of  the 
red  cells.  Examination  of  the  fundus  by  Dr.  Quackenbos  shows 
nothing  abnormal.  Wassermann  reaction  is  negative.  On  the  26th 
I  examined  the  blood  and  found  a  high  color  index,  with  much  ab- 
normal staining  and  stippling,  but  no  other  changes  in  the  red  cells 
and  no  abnormal  variations  of  the  white  cells.  X-ray,  No.  18,631, 
shows  areas  of  rarefaction,  average  size  that  of  a  twenty-five-cent 
piece,  throughout  the  skull  bones,  also  suggestions  of  similar  proc- 


396  DIFFERENTIAL   DL\GNOSIS 

esses  on  one  or  two  points  on  each  humerus  and  quite  clear  evidence 
of  a  similar  tumor  on  one  or  two  ribs.  The  sternum,  pelvic  bones,  and 
scapulcT  are  negative. 

Discussion. — This  patient  has  been  losing  strength  for  a  year  and 
is  20  pounds  under  weight,  yet  his  local  symptoms  are  confined  to  the 
last  three  months,  when  there  appeared  a  group  of  symptoms  con- 
lined  to  the  head,  namely,  palpable  lumps,  headache — more  or  less 
relieved  by  nosebleed — and  a  squint.  Physical  examination  shows 
that  there  is,  in  addition,  an  enlargement  of  the  liver  and  spleen,  a 
curious  atypical  anemia,  and,  most  significant  of  all,  the  Bence- Jones 
body  in  the  urine.  In  the  dift'erential  diagnosis,  chloroma  may  be 
excluded  by  the  blood  examination.  Hypernephroma  is  possible, 
but  the  presence  of  the  Bence-Jones  body  is  strongly  against  it. 
Moreover,  hypernephroma  is  rarely  associated  with  any  such  anemia. 
Syphilitic  gummata  are  not  associated  with  the  presence  of  the 
Bence-Jones  body  in  the  urine,  and  after  a  duration  of  three  months 
would  probably  have  involved  the  skin.  Moreover,  there  are  no 
other  manifestations  of  syphilis.  The  x-ray  examination  excludes 
syphilis  and  shows  lesions  quite  unlike  those  of  metastatic  hyper- 
nephroma. Indeed,  our  radiologists  were  quite  ready  to  make  the 
diagnosis  of  multiple  myeloma  from  the  x-ray  picture  alone. 

Outcome. — A  bit  of  tumor  No.  2  was  excised  on  the  25th  and  ex- 
amined by  Dr.  James  H.  Wright.  He  considered  it  to  be  a  myeloma 
of  the  plasma-cell  type.  The  excised  tumor  was  embedded  in  a  crater 
of  bone  with  a  sharp  edge.  A  blunt  instrument,  inserted  i  cm.  over 
the  edge  of  the  crater,  did  not  strike  bottom.  March  3d  the  patient's 
wife  insisted  on  taking  him  away.  He  died  early  in  the  following 
May. 

Case  162 

A  laborer  of  eighteen  entered  the  hospital  July  12,  191 1.  Nine 
years  ago  the  patient  had  irregular  chills  and  fever  for  six  months. 
It  was  called  "malaria,"  but  there  was  no  blood  examination.  He  was 
never  disabled  except  during  chills.  There  is  no  other  malaria  in 
his  region.  He  has  never  been  out  of  Massachusetts.  November, 
1910,  he  had  pain  in  his  ankles,  which  prevented  him  from  working 
all  winter,  and  was  associated  with  a  gradually  increasing  weakness. 
During  May,  191 1,  he  gained  somewhat  in  strength  and  weight,  but 
otherwise  he  has  been  losing.  In  March,  191 1,  lumps  appeared  in 
the  right  side  of  his  neck,  but  they  are  now  smaller  than  they  were  in 
March.     His  best  weight  was  143  pounds  in  November,   19 10,  in 


GLANDS 


397 


clothes;  now  he  weighs  105  pounds,  without  clothes.  Save  for  weak- 
ness he  still  feels  perfectly  well,  but  has  done  no  work  since  November, 
1910. 

Physical  examination  showed  very  poor  nutrition;  normal  pupils 
and  reflexes.  Enlarged  glands  were  palpable  in  the  neck,  on  the  right 
side  of  which  is  a  firm,  adherent,  insensitive  mass,  10  by  6  cm.,  with  a 
few  smaller  masses  at  its  edges.  Other  glands,  the  size,  of  peas  or 
beans,  were  to  be  found  on  both  sides  of  the  neck.  The  axillary  glands 
were  nearly  as  large  as  a  pigeon's  egg.  The  groin  glands  were  not 
enlarged.  The  chest  was  negative;  the  edge  of  the  spleen  reached 
nearly  to  the  navel.     The  edge  of  the  liver  was  also  easily  palpable. 


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There  was  no  edema.  The  course  of  the  temperature  is  seen  in  Fig. 
137.  The  red  cells  numbered  2,000,000  at  entrance  and  declined  in 
a  fortnight  to  1,000,000;  later,  to  somewhat  below  that  point,  where 
they  continued  up  to  the  loth  of  August.  The  course  of  the  white 
cells  is  seen  in  the  accompanying  chart  (Fig.  138).  The  stained  smear 
showed  almost  no  achromia,  no  macrocytosis,  considerable  deformity, 
occasional  abnormal  staining.  Blood-plates  diminished.  By  the 
29th  of  July  there  was  marked  achromia,  and  on  the  loth  of  August 
considerable  stippling.  The  polynuclears  were  hardly  larger  than 
red  cells.  The  patient  had  severe  nosebleed  soon  after  entrance,  the 
source  of  which  could  not  be  located  by  a  laryngologist.     A  spray  of 


398 


DIPFERENTIAL  DIAGNOSIS 


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GLANDS  399 

adrenalin,  i :  10,000,  four  times  a  day  in  both  nostrils,  checked  the 
bleeding. 

Discussion. — No  one  could  have  any  considerable  doubt  regard- 
ing the  diagnosis  of  this  case,  provided  he  examined  the  blood  at  all, 
and  with  such  glandular  and  splenic  enlargements  I  fancy  that  few- 
would  to-day  neglect  blood  examination.  Taking  together  the  re- 
sults of  blood  examination  and  the  blood-picture,  we  have  a  fairly 
typical  case  of  what  used  to  be  called  acute  lymphatic  leukemia,  or  of 
what  is  now  interpreted  as  the  sudden  outpouring  of  lymphoblastoma- 
tous  cells  into  the  blood-stream. 

I  have  called  attention  to  the  fact  that  for  many  months  this 
patient  complained  of  but  little  but  weakness;  that  the  appearance 
of  the  lumps  in  his  neck  occurred  considerably  later,  and  that  during 
this  period  of  weakness  the  diagnosis  could  probably  have  been  made 
by  blood  examination.  I  have  twice  made  such  a  diagnosis  in  a 
patient  complaining  of  nothing  but  weakness  and  presenting  no 
glandular  or  splenic  enlargements. 

A  second  point  of  interest  is  the  remarkable  leukopenia  during  the 
last  weeks  of  the  patient's  life.  On  the  8th  of  August  the  number  of 
white  cells  was  only  600  per  cubic  millimeter.  Such  a  terminal  fall 
in  the  leukocyte  count  is  not  uncommon  in  cases  of  this  type.  Some- 
times the  leukopenia  is  the  result  of  infection,  streptococcus  septi- 
cemia, pneumonia,  or  erysipelas;  sometimes,  as  in  this  case,  its  cause 
is  entirely  obscure. 

Outcome. — There  was  no  improvement,  and  the  patient  left  the 
hospital  on  the  12th  of  August. 

Case  163 

A  printer  of  twenty-six  entered  the  hospital  November  8,  191 1. 
The  patient's  wife  has  one  child,  now  a  month  old  and  apparently 
healthy.  A  year  ago  she  had  a  miscarriage,  and  two  years  ago  a  baby 
born  prematurely  at  the  eighth  month.  The  patient  has  always  been 
well  until  three  weeks  ago  and  denies  venereal  disease.  Three  weeks 
ago,  after  recovery  from  a  slight  sore  throat,  he  noticed  a  swelling  in 
the  left  side  of  his  neck.  This  swelling  reached  its  present  size  in 
about  two  weeks  and  has  not  changed  in  the  past  week.  A  week  ago 
a  swelling  began  on  the  other  side  of  the  neck  and  was  accompanied 
by  some  pain.  He  has  noticed  sweating  in  the  night  several  times, 
especially  at  the  beginning  of  this  illness.  His  best  weight  is  142 
pounds;  present  weight,  128  pounds.  He  has  worked  steadily,  though 
feeling  unusually  weak.     His  family  history  is  excellent.     He  comes  in 


400 


DIFFERENTIAL   DIAGNOSIS 


from  the  Out-patient  Department  with  a  diagnosis  of  "acute  adenitis 
of  unknown  origin." 

Physical  examination  showed  poor  nutrition,  pallor,  pupils  slightly- 
irregular  and  reacting  very  sluggishly.  In  the  left  side  of  the  neck 
was  a  mass  of  glands  the  size  of  a  baseball,  hard,  not  tender,  showing 
no  fluctuation.  Below  this  and  above  the  clavicle  were  small,  hard, 
discrete,  insensitive  glands.  On  the  right  side  of  the  neck  a  gland  the 
size  of  a  large  pecan  nut  was  movable,  insensitive,  not  fluctuant.  No 
other  enlarged  glands  detected.  The  teeth  in  very  fair  condition. 
The  throat  showed  general  reddening  and  the  hard  and  soft  palates 
look  granular.     The  chest  and  abdomen  were  negative.     The  artery 


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fclWc^..        /        II  II    i    1    1    1-  /       II      :    :  ■    1  /    /              1-      \    ■    1   1  1     III     -    '■■ 

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106 

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Fig.  139. — Chart  of  Case  163. 


walls  showed  slight  fibrous  thickening.  The  reflexes  were  normal. 
Blood-pressure,  82  mm.  Hg.,  systolic;  55  mm.  Hg.,  diastolic,  at 
entrance.  A  month  later,  ico  mm.  Hg.,  systolic;  50  mm.  Hg.,  dias- 
tolic; December  9th,  no  mm.  Hg.,  systolic;  60  mm.  Hg.,  diastolic. 
The  course  of  the  temperature  is  seen  in  Fig.  139.  The  urine  was 
negative.  The  blood  showed  red  cells,  3,200,000;  white  cells,  10,000; 
hemoglobin,  72  per  cent.  Stained  smear  showed  moderate  achromia, 
a  rare  stippled  cell,  and  slight  variations  in  size  and  shape.  Differen- 
tial count  showed  a  slight  polynuclear  leukocytosis. 

During  his  stay  in  the  hospital  the  red  cells  rose  to  3,500,000; 
the  white,  to  13,000.     There  was  no  other  considerable  change  in  the 


GLANDS  401 

blood.  Wassermann  reaction  was  negative.  A  throat  consultant 
thought  the  glands  were  of  tonsillar  origin  and  advised  removal  of  the 
tonsils.  Dr.  G.  F.  Balch  advised  no  operation.  On  the  14th  of  No- 
vember a  gland  was  removed  from  the  neck  for  diagnosis. 

Discussion. — There  is  a  good  deal  in  the  case  to  suggest  syphilis, 
for,  although  the  patient  denies  venereal  disease,  his  wife  has  had  one 
miscarriage  and  one  premature  child.  The  pupils  have  points  in 
common  with  those  seen  in  tabes,  and  for  a  considerable  period  the 
glands  were  smooth,  hard,  and  insensitive,  Uke  those  seen  in  syphilis. 

The  anemia,  the  fever,  the  loss  of  weight,  the  night-sweats  are 
all  perfectly  consistent  with  the  diagnosis  of  syphiHs.  On  the  other 
hand,  the  negative  Wassermann  reaction  and  the  very  low  blood- 
pressure  militate  to  a  certain  extent  against  this  diagnosis. 

It  is  of  interest  that  the  consultant  from  the  throat  department 
considered  the  glands  of  tonsillar  origin  and  advised  tonsillectomy, 
although  it  would  be  hard  to  explain  the  anemia,  the  low  blood- 
pressure,  and  the  loss  of  weight  and  strength  upon  this  hypothesis. 

Tuberculosis  and  lymphoblastoma  remain.  Between  these  dis- 
eases only  histologic  examination  can  decide.  The  low  blood-pressure 
slightly  favors  the  former. 

Outcome. — Dr.  W.  F.  Whitney  reported  that  the  gland  showed 
increase  of  follicles  and  some  small  cheesy  centers,  with  large  giant 
cells  and  an  occasional  epitheloid  cell.  Diagnosis,  tuberculosis.  On 
the  20th  the  tonsils  were  removed.  One  of  them  examined  in  paraflfin 
section,  by  Dr.  J.  H.  Wright,  showed  typical  tuberculosis.  An 
emulsion  of  the  tonsil  in  salt  solution  was  made,  and  20  minims  in- 
jected in  a  guinea-pig  November  20th.  December  25th  the  pig 
was  killed.  Autopsy  showed  tuberculosis  of  the  glands  and  spleen. 
The  patient  ran  a  higher  fever  after  the  tonsillectomy,  but  otherwise 
seemed  to  feel  well.  No  signs  developed  in  the  lungs.  He  seemed 
considerably  better.  He  ate  well  and  nothing  could  be  found  in  his 
lungs,  but  on  the  9th  tubercle  bacilK  were  found  in  his  sputum.  He 
promised  to  report  to  the  Social  Service  in  the  Out-patient  Depart- 
ment and  was  accordingly  discharged.  He  went  to  Rutland  State 
Tuberculosis  Hospital,  and  died  there  November  13,  191 2. 

Case  164 

A  Greek  baker  of  twenty-one  entered  the  hospital  April  23,  191 2. 
For  three  months  he  has  had  lumps  on  each  side  of  his  neck,  gradually 
increasing  in  size.  He  feels  perfectly  well  in  other  respects.  Family 
history  and  past  history  good.     He  denies  venereal  disease. 

Vol.  11—26 


402  DIFFERENTIAL  DIAGNOSIS 

Physical  examination  shows  good  nutrition.  Glandular  enlarge- 
ment on  both  sides  of  the  neck,  extending  from  the  mastoid  process 
down  behind  the  sternomastoid.  The  glands  are  smooth,  rounded, 
fairly  movable,  not  attached  to  the  skin,  and  varying  from  ^  to 
5  cm.  in  diameter.  The  teeth  and  tonsils  are  normal.  In  the  axillae 
are  several  glands,  i^  cm.  in  diameter.  The  inguinal  glands  not 
enlarged.  The  chest  negative.  The  edges  of  the  liver  and  spleen  are 
felt  on  deep  inspiration.  No  fever  in  a  week's  observation.  Blood 
and  urine  negative.     Blood-pressure,  135  mm.  Hg. 

Discussion. — Tuberculosis,  syphilis,  and  lymphoblastoma  were 
considered  in  the  difTerential  diagnosis,  the  latter  being,  upon  the 
whole,  thought  most  probable.  Unfortunately,  no  Wassermann 
reaction  was  tried,  and  there  is  nothing  in  the  case,  as  recorded,  to 
exclude  sj-phiHs.  The  presence  of  splenic  and  hepatic  enlargement 
slightly  favors  this  disease,  although  in  Greeks  and  other  Mediter- 
ranean peoples  we  often  find  such  enlargements  without  any  known 
cause. 

The  fact  that  the  lumps  have  existed  for  three  months  without 
softening  or  involving  the  skin  is  rather  against  tuberculosis,  but  by 
no  means  exclusive. 

Outcome. — A  gland  excised  from  the  neck  showed  on  microscopic 
examination  confluent  foci  of  epithelioid  and  small  round  cells,  with 
cheesy  degeneration  and  scattered  giant  cells.  Diagnosis — tubercu- 
losis. The  patient  preferred  to  continue  treatment  in  the  Out-patient 
Department,  and  was  accordingly  discharged  on  the  2Qth. 

January  i,  19 13,  the  glands  were  considerably  swollen.  Soon  after 
this  he  returned  to  Greece. 

Remarks.— The  case  is  inserted  to  indicate  the  frequent  im- 
possibility of  diagnosis  without  histologic  examination. 

Case  165 

A  farmer  of  twenty- three  entered  the  hospital  May  25,  191 2. 
The  patient's  father  died  of  locomotor  ataxia.  His  family  history, 
as  well  as  his  past  history,  otherwise  good.     He  denies  venereal  disease. 

Four  months  ago  he  noticed  a  lump  in  the  left  side  of  his  neck 
and  in  his  left  shoulder  and  arm  a  shght  aching,  which  gradually  wore 
away.  Three  months  ago  a  similar  mass  appeared  in  the  left  axilla. 
Two  months  ago  a  lump  appeared  in  the  right  side  of  his  neck  and  a 
month  ago  one  in  the  right  axilla.  He  has  lost  weight  and  strength, 
and  for  two  weeks  has  done  no  work.  Walking  causes  his  thighs  to 
ache.     His  appetite  and  digestion  are  good.     He  has  no  fever  as  far 


GLANDS 


403 


as  he  knows.     Four  months  ago  he  weighed  165  pounds,  with  clothes; 
now,  142  pounds,  without  clothes. 

Physical  examination  shows  a  well-developed  muscular  young  man 
with  normal  pupils  and  reflexes.  Heart  and  abdomen  negative.  On 
each  side  of  the  neck,  between  the  sternomastoid  and  the  trapezius, 
is  a  mass  of  glands,  larger  on  the  left  side.  Similar  masses  in  the 
axillae.  The  left  side  5  cm.  in  diameter,  the  right  somewhat  smaller. 
No  enlargement  of  inguinal  or  epitrochlear  glands.     The  left  lung 


Fig.  140. — Chest  signs  in  Case  165. 

shows  at  the  apex,  posteriorly,  dulness,  bronchial  breathing  and 
whisper,  normal  fremitus.  No  rales.  At  the  base,  dulness,  de- 
creased whisper  and  fremitus,  normal  breathing.  The  substernal 
dulness  is  increased  (Figs.  140,  141).  The  course  of  the  temperature 
is  shown  in  Fig.  142.  The  urine  is  normal.  Blood-pressure  normal. 
The  blood  shows  22,000  white  cells,  with  89  per  cent,  polynuclears. 
There  is  slight  secondary  anemia. 

Discussion. — We  have  some  reason  to  suspect  that  the  patient's 
father  was  sj^philitic,  but  there  is  no  positive  evidence  of  this  disease 


404 


DIFFERENTIAL  DIAGNOSIS 


in  the  patient  himself.  Generalized  adenitis,  with  loss  of  flesh  and 
strength,  fever,  anemia,  and  polynuclear  leukocytosis,  are  signs  com- 
patible with  any  of  the  three  causes  of  general  glandular  enlargement 
most  frequently  demanding  consideration  in  differential  diagnosis — 
syphihs,  tuberculosis,  and  lymphoblastoma. 

But  against  tuberculosis  is  the  presence  of  mediastinal  pressure 
s>Tnptoms,  such  as,  so  far  as  I  know,  are  never  produced  by  tuber- 


T3uU  brontVucOr 
"by^.a.thiYv.q  CL-nS 
wl\"n>)>tir.  +remiTi/6 
-norma).   No     . 


\\}\\  -Trtmi  +  us 
SttveaseS. 

orvnal. 


Chest  signs  in  Case  165. 


culous  glands.  I  have  called  the  pulmonary  signs  those  of  mediastinal 
pressure,  because  of  the  absence  of  rales  and  sputum  and  because 
of  their  association  with  an  increase  of  substernal  dulness.  But  for 
these  facts  the  lung  signs  might  well  be  interpreted  as  tuberculosis. 

Leaving  tuberculosis  out  of  consideration,  we  have  to  consider 
whether  syphilis  would  be  likely  to  produce  so  much  glandular  enlarge- 
ment without  any  other  lesion,  and  especially  whether  it  could  account 
for  the  intrathoracic  signs.  The  substernal  dulness  might  be  accounted 
for  by  an  aneurysm  and  the  pulmonary  pressure  signs  in  the  same  way. 
It  would  be  rather  unusual,  however,  to  find  such  an  aneurysm  with- 
out any  paralysis  of  the  vocal  cords  or  evidence  of  tracheal  displace- 


GLANDS 


405 


ment.  X-ray  evidence  of  aneurysm  should  be  sought  for.  Does  the 
tumor  pulsate?  Is  it  typically  situated?  The  Wassermann  reaction 
should,  of  course,  be  done.  If  negative  answers  are  obtained  to  all 
these  questions,  the  diagnosis  should  be  lymphoblastoma. 

Outcome. — An  axillary  gland  was  removed  May  28th,  and  showed 
entire  disappearance  of  lymphoid  structure  and  replacement  by 
small,  round  cell  growth  with  a  marked  excess  of  fibrous  tissue.     The 


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Fig.  142. — Chart  of  Case  165. 


cells  were  a  little  larger  and  more  irregular  than  normal  lymphoid 
cells.  Diagnosis — lymphoma.  X-ray,  No.  20,850,  showed  a  shadow 
in  the  left  side  of  the  chest,  more  dense  at  the  apex  than  at  the  base. 
The  shadow  at  the  base  suggested  a  small  amount  of  fluid.  There 
were  enlarged  glands  at  the  roots  of  each  lung.  The  shadow  of  the 
heart  and  great  vessels  was  generally  enlarged.  The  patient  entered 
only  for  diagnosis,  and  left  the  hospital  on  the  29th. 


CHAPTER   VII 

BLOOD  IN  THE  STOOLS  (MELENA) 

Melena  means  dark  blood  in  the  stools,  so-called  tarry  stools. 
When  this  is  present  it  means  that  the  blood  has  been  poured  out 
high  up  in  the  intestinal  tract.  In  practically  every  case  this  means 
the  gullet,  stomach,  or  duodenum.  It  is  very  rare  to  see  a  tarry  stool 
as  a  result  of  any  hemorrhage  in  the  small  intestine. 

Hemorrhages  in  the  large  intestine  or  in  the  rectum  show  them- 
selves by  the  expulsion  of  relatively  fresh  and  unaltered  blood.  The 
latter  are  common  and  usually  unimportant.  The  former,  tarry 
stools,  are  relatively  rare  and  much  more  important.  They  often 
escape  observation,  as  their  color  is  much  less  alarming  and  they 
make  less  impression  upon  the  patient's  mind. 

Besides  gross  hemorrhages  of  either  of  the  types  just  mentioned, 
we  have  minute  hemorrhages,  demonstrable  by  chemical  tests,  such  as 
guaiac  or  benzidin.  The  latter  are  of  especial  importance  in  connec- 
tion with  gastric  cancer  and  gastric  ulcer. 

Fresh  blood  in  the  stools  is  due  in  the  vast  majority  of  cases  to 
piles  in  case  the  patient  is  constipated,  or  to  enteritis  in  case  the 
bowels  are  loose.  These  are  the  common  and  relatively  unimportant 
causes  for  the  appearance  of  blood  in  the  stools.  It  should  be  remem- 
bered, however,  that  in  elderly  persons  cancer  of  the  rectum  is  not 
infrequently  mistaken  for  piles  and  neglected  accordingly.  Every 
case  of  rectal  hemorrhage  occurring  in  an  elderly  person  should  be 
carefully  investigated,  in  order  to  exclude  the  possibility  of  cancer. 
The  diagnosis  of  hemorrhoids,  internal  or  external,  is  easily  made  by 
inspection,  especially  if  a  proctoscopic  tube  is  used. 

The  supposed  relationship  between  hemorrhoids  and  cirrhosis  of  ^^to  fc, 
the  Uver  is  probably  legendary.  There  is  no  good  reason  to  believe  ^■^-^^^ 
that  piles  occur  any  more  frequently  in  cirrhotics  than  in  other  per-  '  "** 
sons  of  the  same  age. 

Next  to  hemorrhoids  and  acute  diarrheas,  cancer  of  the  intestine 
or  of  the  stomach  is  the  most  important  cause  of  a  discharge  of  blood 
with  the  feces.  The  amount  of  blood  thus  discharged  is  usually 
very  small,  and  recognizable  only  by  the  chemical  tests  above  men- 
tioned. In  cancerous  cases  the  discharge  of  blood  is  usually  steady, 
406 


Blood  in  the  Stools 


(GROSS    BLEEDING— not    MICROSCOPIC) 


HEMORRHOIDS  ■■■^■^^■l^ii^HBHIHHHHHBBBi  2290 

COLITIS,    ULCERATIVE)  

COLITIS,   PROCTITIS,  Y  ■■^^^■■i^^Hl  518 
AND  "DYSENTERY"  ) 

CANCER  OF  RECTUM  l^^^^iH^HHl  475 

PEPTIC  ULCER  l^^K^am^mM  370 

TYPHOID'  ■^■■■■■l  332 

CANCER  OF  STOMACH  ^^^Hi  209 

CANCER  OF  SIGMOID  ^^  117 

CIRRHOSIS  OF  LIVER  ■  58 

BILHARZIA  DISEASE  I  4 


^  Disproportionately  large  because  of  the  abnormally  great  number  of  typhoid  cases 
treated  at  this  hospital. 


(In  phthisis,  pulmonary  blood  is  often  swallowed  and  passed  by  rectum.     How  often 
cannot  be  said.) 


407 


4o8  DIFFERENTIAL  DIAGNOSIS 

though  small.  In  gastric  ulcer,  on  the  other  hand,  it  is  usually  inter- 
mittent, and  the  amount  discharged  is  usually  larger  than  in  cancer. 
Tarry  stools — that  is,  the  expulsion  of  a  large  quantity  of  blood 
changed  by  its  retention  in  the  intestine — are  rarely  seen  in  gastric 
cancer  or  in  any  affection  other  than  peptic  ulcer  or  cirrhotic  liver. 

Ulcerations  of  the  large  intestine,  whether  acute  or  chronic,  usually 
discharge  pus  as  well  as  blood  into  the  stools,  and  are  to  be  distin- 
guished in  this  way  from  the  causes  previously  mentioned. 

In  typhoid  fever  the  hemorrhages  are  usually  from  the  large 
intestine  or  the  lowest  portion  of  the  small  intestine,  and  the  blood 
is,  therefore,  relatively  fresh  or  but  slightly  altered. 

Syphilis  of  the  lower  portion  of  the  colon  usually  shows  itself  for 
the  first  time  by  symptoms  of  intestinal  stricture,  but  occasionally  in, 
the  earlier  stages  of  the  same  disease  blood  is  discharged  in  the  stools, 
and  is  then  often  attributed  to  hemorrhoids.  Intussusception  pro- 
duces bloody  stools  in  a  relatively  small  proportion  of  cases.  The 
same  is  true  of  infarction  of  the  intestine,  which  usually  results  in 
symptoms  indistinguishable  from  those  of  intestinal  obstruction. 

Bilharzia  disease  is  a  common  cause  of  bloody  stools  in  tropical 
climates. 

It  must  also  be  remembered  that  blood  swallowed,  either  as  the 
result  of  a  nosebleed  or  pulmonary  hemorrhage  or  from  some  ulcera- 
tive condition  of  the  mouth,  will  appear  in  the  stools  and  may  give 
rise  to  the  mistaken  belief  that  the  intestine  or  the  stomach  is  diseased. 
A  careful  history  of  the  case  will  usually  determine  this  point. 

Case  166 

An  Itahan  laborer  of  twenty  entered  the  hospital  November  17, 
1902.  About  a  month  and  a  half  ago  the  patient  began  to  have  diffi- 
culty with  his  bowels,  frequent  desire  to  defecate,  but  would  pass  only 
blood  mixed  with  pus  and  mucus.  This  continued  until  three  weeks 
ago,  when,  under  medicine,  brown,  watery  movements  began.  During 
the  last  five  days  he  has  passed  very  Httle  blood  or  pus.  He  has  never 
had  an  attack  like  this  before.  Just  before  movements  there  is  a 
good  deal  of  abdominal  pain.  The  patient  has  lost  no  weight,  has  a 
good  appetite,  no  nausea  or  vomiting. 

Physical  examination  showed  good  nutrition,  and  was  otherwise 
negative,  save  as  related  to  the  abdomen,  which  showed  dulness  in 
the  right  flank,  not  changing  with  position.  There  was  some  general 
tenderness,  most  marked  in  the  left  iliac  region.  The  temperature 
was  100°  F.;  pulse,  120;  respiration,  32.      Widal  reaction  negative. 


BLOOD   IN   THE   STOOLS    (mELENA)  409 

The  white  cells  were  26,700;  hemoglobin,  98  per  cent.  The  urine 
was  normal  in  amount;  specific  gravity,  1028;  slightest  possible  trace 
of  albumin;  rare  hyaline  and  fine  granular  cast. 

The  patient  seemed  to  have  little  or  no  control  of  the  sphincter. 
The  stools  were  semisolid  in  consistency,  dark  brown  to  blue  in 
color.  Most  of  them  contained  a  little  blood.  Rectal  examination 
showed,  projecting  into  the  rectum  and  narrowing  its  lumen  as  far 
as  the  finger  can  reach,  frequent  nodules,  varying  in  size  from  that 
of  a  large  bean  to  that  of  a  horse  chestnut.  They  were  very  hard. 
A  surgical  consultant  could  not  decide  whether  the  trouble  was  syph- 
ilitic or  malignant,  but  favored  the  former  and  advised  antisyphilitic 
treatment,  which  was  immediately  given,  according  to  the  local 
custom  of  that  day,  in  the  form  of  potassium  iodid,  5  gr.  three  times 
a  day,  increasing  5  gr.  each  day. 

Discussion. — The  symptoms  are  those  of  proctitis  with  fever  and 
leukocytosis  in  a  man  of  twenty.  Such  a  condition  would  be  of  no 
importance  if  it  were  acute.  Most  brief  and  mild  diarrheas  begin  in 
this  way,  but  in  this  case  the  symptoms  have  lasted  six  weeks  and 
very  little  true  fecal  matter  is  seen  in  the  discharges.  Taking  these 
facts  alone,  one  would  conjecture  that  a  chronic  ulcerative  proctitis 
or  colitis  is  the  cause  of  his  troubles.  Without  rectal  examination, 
such  a  diagnosis  would  probably  never  have  been  questioned.  The 
whole  interest  and  significance  of  the  case  centers  around  the  results 
of  rectal  examination. 

Nodules,  such  as  those  here  described,  may  be  due  to  bilharzia 
disease,  to  syphihs,  or  to  cancer,  possibly  also  to  a  lymphoblastoma,  al- 
though in  this  case  they  would  certainly  appear  elsewhere.  The  latter 
observation  applies  to  all  of  the  other  possible  causes  known  to  me. 

Outcome. — A  week  later,  as  there  was  no  improvement,  a  small 
piece  of  the  rectal  growth  was  removed.  Examination  by  Dr.  J.  H. 
Wright  showed  a  tissue  characteristic  of  colloid  carcinoma.  The 
cause  was  explained  to  the  patient,  and  his  friends  then  decided  to  take 
him  back  to  Italy.     He  left  the  hospital  on  the  4th  of  December. 

Remarks. — This  case  shows  that  one  must  always  consider  cancer 
of  the  rectum,  no  matter  how  young  the  patient  is.  I  remember  a 
similar  case  which  I  saw  many  years  ago  with  Dr.  Reginald  H.  Fitz. 
There  was  much  in  the  case  to  suggest  cancer  of  the  sigmoid,  but  as 
the  patient  was  only  twenty-one  years  of  age  we  excluded  this  from 
consideration  wrongly,  as  the  outcome  of  the  case  showed.  The 
main  lesson  of  the  case  is  the  importance  of  rectal  examination,  digi- 
tal or  ocular,  in  all  cases  of  rectal  disease  lasting  more  than  a  few  days. 


4IO 


DHTERENTIAL  DIAGNOSIS 


Case  167 

A  jeweler  of  twenty-nine  entered  the  hospital  May  9,  1904. 
Twelve  days  ago  the  patient  had  a  severe  headache  and  felt  weak. 
He  took  to  bed,  but  did  not  stay  there.  After  getting  up  again,  how- 
ever, he  grew  rapidly  worse ;  six  days  ago  he  woke  in  the  night  and  had 
a  profuse  hemorrhage  from  the  bowels,  followed  four  days  ago  by  an- 
other. The  day  before  this  last  hemorrhage  he  took  to  his  bed  for  the 
second  time  and  has  remained  there  since.  Except  for  the  hemor- 
rhages, his  bowels  have  not  moved  at  all  as  far  as  he  knows.  His 
family  history  and  past  history  are  excellent. 

Physical  examination  is  negative,  except  as  relates  to  the  abdomen, 
which  is  markedly  distended,  and,  upon  the  right  side,  somewhat 

rigid.  It  is  tympanitic  throughout  and 
not  tender.  The  temperature  is  103.2°  F.; 
pulse,  130;  respiration,  24.  The  red  cells 
are  2,396,000;  white  cells,  8900;  hemo- 
globin, 55  per  cent.  The  urine  averaged 
40  ounces  in  twenty-four  hours;  specific 
gravity,  1023;  slight  trace  of  albumin; 
rare  hyaline  and  granular  casts.  Widal 
reaction  was  doubtful.  On  account  of 
the  spasm  of  the  abdomen  a  surgical  con- 
sultant saw  the  patient  on  the  9th  and 
found  no  evidence  of  peritonitis.  The 
patient  was  sHghtly  delirious,  but  had 
no  more  hemorrhage  and  the  distention 
gradually  decreased.  On  the  15th  there 
was  evidence  of  a  moderate  cystitis,  and 
the  bladder  was  washed  three  times  a 
day  with  2  per  cent,  boric  acid.  On 
the  17th  the  blood  showed  red  cells, 
4,800,000;  whites,  4400;  hemoglobin,  70  per  cent.  Differential  count 
normal. 

Discussion. — Hemorrhage  from  the  bowels  in  a  patient  previously 
well,  or  comparatively-  well,  is  a  very  rare  occurrence,  or,  at.  any 
rate,  is  very  rarely  recognized.  Intussusception  or  infarction  of  the 
bowel  may  occasionally  produce  such  a  hemorrhage,  but  only  in  con- 
nection with  the  evidences  of  intestinal  obstruction  such  as  are  absent 
here. 

The  different  varieties  of  intestinal  ulceration  from  which  bleed- 


II                  ' 

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Lio 

Fig.  143. — Chart  of  Case  167. 


BLOOD    IN    THE    STOOLS    (mELENA)  4II 

ing  may  occur  do  not  bleed  with  such  suddenness  and  without  pre- 
vious evidences  of  intestinal  irritation. 

I  think  one  would  be  altogether  at  a  loss  for  a  diagnosis  here  but 
for  the  later-  appearance  of  abdominal  distention,  with  fever  and 
delirium.  This  group  of  symptoms  should  make  anyone  of  ordinary 
intelligence  search  carefully  for  evidences  of  typhoid  fever.  There 
are  very  few  causes  for  intestinal  hemorrhage  combined  with  fever. 
Dysentery  may  produce  both  these  symptoms,  but  there  is  no  dysen- 
tery present  in  this  case.  Syphilis  may  do  it,  but  the  symptoms  are 
usually  more  definitely  localized  in  or  near  the  rectum  and  the 
amount  of  blood  discharged  is  smaller.  I  see  nothing  in  the  case  to 
invalidate  a  diagnosis  of  typhoid  fever.  A  doubtful  Widal  reaction 
should  not  weigh  at  all  against  such  a  diagnosis. 

It  is  unusual  to  see  intestinal  hemorrhage  so  early  in  the  course  of 
typhoid.  As  a  rule,  the  bleeding  comes  in  the  latter  weeks  of  the 
disease.  Still  the  case  is  by  no  means  unique,  and  will  be  classed 
as  one  of  ''walking  typhoid,"  with  early  hemorrhage. 

Outcome. — Within  a  few  days  after  this  the  temperature  fell  to 
normal,  having  been  continuously  elevated  before  that  time  (Fig. 
143).  Convalescence  was  uninterrupted.  He  left  the  hospital  on 
the  14th  of  June. 

Case  168 

A  housewife  of  thirty-eight  entered  the  hospital  June  4,  1906. 
Twenty  years  ago  the  patient  first  noticed  bright  blood  and  mucus  in 
the  stools,  which  averaged  six  a  day,  almost  all  of  them  in  the  morning 
and  none  of  them  at  night.  There  was  very  slight  pain  just  before 
movements  and  relieved  by  them.  Some  of  the  discharges  contained 
fecal  matter,  others  consisted  wholly  of  blood  and  mucus.  There  was 
no  incontinence.  Nine  months  ago  she  began  treatment  by  daily 
irrigations,  and  improved  steadily  up  to  three  weeks  ago.  For  ten 
weeks  there  was  no  blood  in  the  discharges,  and  the  movements  were 
reduced  to  one  daily  and  of  normal  consistency. 

Three  weeks  ago  the  blood  reappeared  and  the  discharges  be- 
came more  frequent.  For  nearly  a  year  she  has  lived  on  nitrogenous 
diet  and  has  lost  in  weight,  strength,  and  color.  Except  for  lack  of 
appetite  and  weakness  she  feels  perfectly  well,  and  throughout  the 
trouble  has  been  able  to  do  most  of  the  work  for  her  husband  and 
three  children. 

Physical  examination  showed  good  nutrition.  The  patient  did 
not  look  sick.     There  was  a  soft,  systoHc  murmur,  loudest  in  the 


412  DIFFERENTIAL  DIAGNOSIS 

pulmonary  area,  heard  all  over  the  precordia  and  faintly  in  the  axilla. 
The  abdomen  was  tympanitic  in  the  center,  dull  in  the  flanks,  the  dul- 
ness  not  shifting  with  change  of  position.  During  the  five  weeks  of 
her  stay  in  the.  hospital  the  evening  temperature  often  reached  99.5° 
or  99.8°  F.,  usually  normal  in  the  morning.  The  pulse  during  the 
first  two  weeks  was  between  80  and  90;  after  that,  between  90  and  100. 
The  stools  contained  a  moderate  amount  of  mucus  and  were  positive 
to  guaiac.  Microscopically,  they  contained  no  blood  or  eggs,  but 
many  undigested  muscle-fibers.  The  patient  was  put  on  nitrogenous 
diet,  colonic  irrigations  at  116°  F.  twice  a  day,  orphol  5  gr.,  three  times 
a  day,  after  meals.  7  mg.  old  tuberculin  was  injected,  without  any 
reaction.  Proctoscopic  examination  showed  no  ulcerations  in  the 
rectum.  The  blood  and  pus,  however,  did  not  disappear  from  the 
stools. 

Discussion. — When  the  stools  contain  only  blood  and  mucus, 
dysentery  is  usually  the  diagnosis,  and  by  "dysentery"  in  this  connec- 
tion I  mean  chronic  ulcerative  coHtis.  But  at  first  sight  this  diag- 
nosis seems  to  be  impossible,  because  the  patient  has  been  doing  all 
the  housework  for  a  family  of  four  and  still  shows  good  nutrition. 
Any  one  of  large  cHnical  experience,  however,  has  often  seen  similar 
cases.  It  is  really  extraordinary  how  bad  an  ulcerative  colitis 
may  exist  without  disabling  the  patient  or  even  reducing  his  nutri- 
tion to  any  extent.  In  other  cases,  apparently  no  worse  from  the 
anatomic  and  pathologic  point  of  view,  the  patient  is  utterly  pros- 
trated, emaciated,  and  useless.  I  know  no  way  to  explain  these 
differences. 

In  the  present  case  we  have  dulness  in  the  flanks,  without  any 
shifting  with  change  of  position.  This  physical  sign  is  often  seen  in 
dysenteric  cases,  acute  or  chronic.  The  slight  fever  present  does 
not  help  us  toward  more  accurate  diagnosis.  The  negative  tubercu- 
lin reaction,  on  the  other  hand,  is  of  considerable  importance.  A 
positive  reaction  would  mean  very  little,  but  a  negative  reaction  goes 
far  to  exclude  tuberculosis.  Taking  the  negative  features  of  the  case 
and  the  condition  of  the  stools,  I  do  not  see  how  any  other  diagnosis 
than  ulcerative  coHtis  is  possible. 

In  New  England  one  sees  a  good  many  cases  like  this  in  which 
a  non-amebic,  chronic,  and  largely  afebrile  colitis  arises  without  known 
cause,  and  runs  its  course  either  to  recovery  or  to  a  fatal  termination 
quite  uninfluenced  by  treatment.  Prognosis  is  never  hopeless  as  long 
as  the  patient  is  alive.  I  have  seen  the  most  seemingly  pernicious  and 
virulent  cases  recover  after  all  treatment  had  been  given  up.     On  the 


BLOOD   IN   THE    STOOLS    (mELENA)  413 

other  hand,  cases  which,  Hke  the  present  one,  seem  in  many  respects 
mild  because  their  effect  on  general  nutrition  is  for  months  and  years 
so  slight,  may  at  any  time  be  transformed  into  a  progressive,  finally 
fatal,  disease. 

In  differential  diagnosis  one  might  consider  cancer  of  the  intestine, 
but  the  long  duration  of  the  patient's  illness  mxakes  this  very  im- 
probable, especially  as  no  tumor  has  developed. 

Outcome. — Pills  of  camphor,  opium,  and  tannin  were  tried  from 
June  14th  to  June  29th,  three  times  a  day,  before  meals,  also  tannic 
acid  irrigations,  i  dram  to  the  quart.  None  of  these  methods  of 
treatment  helped  her.     She  left  the  hospital  July  7th,  unreUeved. 

Case  169 

A  Canadian  brick-maker  of  fifty-eight  entered  the  hospital  January 
24,  1910.  After  fifty-seven  and  a  half  years  of  excellent  health  the 
patient  noticed  last  July  that  for  a  period  of  two  weeks  his  stools 
were  tarry  black.  He  felt  well,  however,  until  the  first  of  October, 
when  he  began  to  notice  a  distress  fifteen  minutes  after  eating,  and 
would  often  vomit  soon  after  heavy  food.  Since  this  he  has  vomited, 
as  a  rule,  about  twice  a  week,  a  large  amount  being  ejected  each  time. 
Soon  after  meals,  always  within  an  hour  and  a  half,  he  has  epigastric 
pain  and  gas.  He  has  never  vomited  blood.  Meat  and  eggs  give 
him  special  trouble.  His  appetite  is  fair.  He  has  no  nausea.  Bowels 
are  constipated.  He  sleeps  well.  Since  last  spring  he  has  lost  32 
pounds.     He  gave  up  work  last  August  on  account  of  this  illness. 

Physical  examination  shows  fair  nutrition,  slight  pallor,  the  right 
pupil  irregular  and  not  responding  to  light  or  accommodation.  The 
left  pupil  normal.  Glands  and  reflexes  normal.  Chest  and  abdomen 
negative.  The  capacity  of  the  fasting  stomach  is  28  ounces,  and 
the  wash-water  contains  fragments  of  food  and  shows  a  positive 
guaiac  reaction.  No  free  HCl.  The  lower  border  of  the  stomach 
is  at  the  navel  after  inflation.  After  a  test-meal  free  HCl  is  absent 
and  blood  present.  The  stools  are  strongly  positive  to  guaiac  on 
each  of  five  tests.  Blood  and  urine  normal.  No  fever.  Blood- 
pressure,  105  mm.  Hg. 

Discussion. — The  point  of  special  interest  in  this  case  is  the 
appearance  of  black  stools  as  the  first  or  presenting  symptom  and  at 
a  time  when  the  patient  was  feeling  in  other  respects  weU.  Indeed, 
it  was  not  until  three  months  later  that  the  group  of  gastric  s}Tnp- 
toms  typical  of  gastric  cancer  made  their  appearance.  The  ex- 
istence of  gastric  stasis,  with  a  positive  guaiac  reaction  and  no  HCl, 


414  DIFFERENTIAL  DIAGNOSIS 

in  a  man  of  fifty-eight,  who  has  lost  32  pounds  in  nine  months  and  has 
ahvays  been  well  until  the  present  illness,  leaves  us  little  doubt  that 
gastric  cancer  is  the  diagnosis. 

Why  did  the  patient  hrst  bleed  from  the  bowel?  I  am  unable  to 
say. 

Outcome. — On  the  5th  of  February  operation  showed  a  markedly 
contracted  stomach,  infiltrated  with  new  growth,  from  one  end  to  the 
other.  There  was  not  even  enough  normal  stomach  to  allow  gastro- 
enterostomy. The  patient  was  discharged  February  15th.  A  small 
lymph-node  excised  at  the  time  of  operation  showed  no  (evidences  of 
tumor.     Nevertheless,  he  died  in  January,  191 1. 

Case  170 

An  Irish  laborer  of  twenty-six  entered  the  hospital  March  3,  191 1. 
The  patient's  family  history  was  good  and  his  past  history  unevent- 
ful up  to  the  time  of  the  present  illness.  In  1896  he  enlisted  m  the 
British  Army,  and  was  four  years  in  South  Africa  and  then  a  year 
in  Mauritius,  whence  he  was  invalided  home  on  account  of  the  illness 
next  to  be  described.  In  1900,  when  in  South  Africa,  he  noticed  blood 
in  the  stools  and  in  the  urine,  but  after  a  few  days  off  duty  felt  well, 
and  six  months  later  was  transferred  to  Mauritius.  After  four  months 
there  he  began  to  notice  blood  in  the  urine,  and  stayed  in  a  hospital 
twelve  weeks  without  improvement.  Ever  since  then  he  has  been 
unable  to  work,  and  has  had  blood  in  the  urine  and  pain  on  micturition 
steadily.  He  urinates  about  twenty  times  a  day  and  three  or  four 
times  in  the  night.  Nevertheless,  he  has  done  some  work,  off  and  on, 
until  eight  weeks  ago. 

Physical  examination  was  negative,  except  that  the  urine  con- 
tained considerable  blood  and  pus  and  large  numbers  of  bilharzia 
eggs,  with  spines  at  the  end.  The  blood  was  negative.  No  tem- 
perature in  three  weeks'  observation.  On  one  occasion  there  was  a 
considerable  amount  of  blood  in  the  stools,  but  no  eggs. 

Discussion. — When  blood  appears  both  in  the  stools  and  the 
urine  of  a  patient  who  has  been  in  the  Tropics,  we  should  always 
consider,  first  of  all,  bilharzia  disease  of  the  bladder  and  rectum,  and 
examine  the  urine  and  feces  for  the  characteristic  eggs  with  their 
terminal  or  lateral  spear  point.  In  certain  parts  of  Egypt  and  other 
tropical  regions,  bilharzia  disease  is  by  far  the  commonest  cause  of 
bloody  stools.  In  this  country  it  is  rare,  and,  so  far  as  I  know,  has 
never  occurred  except  in  patients  who  have  brought  it  from  some 
tropical  region. 


BLOOD   IN   THE   STOOLS    (mELENA)  415 

Cancer  of  the  bladder  or  of  the  rectum,  infiltrating  the  wall  inter- 
vening between  the  two  organs,  may  produce  a  simultaneous  dis- 
charge of  blood  in  the  urine  and  feces.  Such  a  growth,  however,  is 
easily  detected  by  rectal  examination  or  by  cystoscopy,  and  at  the 
age  of  twenty-six  would  be  extraordinarily  rare.  Aside  from  tuber- 
culous disease  and  cancer,  there  is  practically  nothing  else  which  can 
produce  a  simultaneous  discharge  of  blood  in  the  urine  and  feces, 
although,  in  hemorrhagic  diseases,  such  an  association  is  occasionally 
to  be  observed. 

Outcome. — Bilharzia  eggs  were  later  found.  The  patient  was 
given  0.6  gram  of  "606"  intravenously  in  alkaline  solution,  and,  after 
a  moderate  reaction,  left  the  hospital  on  the  20th  of  March. 

Case  171 

An  Italian  laborer  of  forty-one  entered  the  hospital  March  20, 
191 1.     The  patient  lived  in  southern  Italy  until  fifteen  years  ago, 
then  was  in  Russia  five  years,  then  in  South  America  a  few  months. 
For  the  past  ten  years  he  has  been  in  Massachusetts.     He  had  syph-  ^ 
ilis  four  years  ago.     Up  to  three  years  ago  he  was  a  heavy  drinker  ofy 
wine,  beer  and  whisky,  and  was  often  drunk. 

For  three  or  four  years  he  has  noticed  blood  with  every  move- 
ment of  the  bowels.  The  movements  are  soft  and  occur  four  or  five 
times  a  day,  but  cause  no  pain.  His  appetite  is  ravenous.  Any 
considerable  amount  of  solid  food  makes  his  bowels  move  more  fre- 
quently, so  that  he  has  lived  mostly  on  eggs,  milk,  and  macaroni. 
For  the  past  four  months  he  says  he  has  had  to  give  up  his  work  as  a 
ditch  digger  on  account  of  coldness  of  the  feet.  He  has  lost  no  weight 
or  strength,  and  feels  well  in  other  respects. 

Physical  examination  showed  a  well-nourished  patient  who  did  not 
look  sick.  The  stools  at  this  time  showed  no  amebae  or  other  ab- 
normality, Wassermann  reaction  was  negative,  and,  after  two  weeks' 
observation,  with  normal  temperature,  blood,  and  urine,  and  a  sys- 
tolic blood-pressure  of  135  mm.  Hg.,  he  left  the  hospital. 

Discussion. — Three  causes  for  bloody  stools  are  suggested  by  this 
history — syphilis,  cirrhosis  of  the  liver,  and  amebic  dysentery.  Of 
cirrhosis  we  have  no  evidence.  Syphilis  of  the  rectum  or  sigmoid 
should  give  us  some  evidence  of  intestinal  stenosis.  Nothing  of  the 
kind  is  present  here.  The  further  determination  of  the  disease  rests 
upon  the  study  of  the  stools  and  proctoscopic  examination.  If 
nothing  particular  is  found  in  the  stools,  a  diagnosis  of  ulcerative  coKtis, 
cause  unknown,  will  be  our  best  surmise.     In  this  case,  as  in  one  of 


41 6  DIFFERENTLA.L  DIAGNOSIS 

those  previously  recorded,  the  good  nutrition  of  the  patient  is  in 
striking  contrast  with  the  long  duration  and  apparent  severity  of  his 
disease. 

Outcome. — Later  on  he  returned  and  amebae  of  the  histolytic 
t\^e  were  found. 

Remarks. — Unfortunately,  this  patient  was  not  given  the  benefit 
of  the  emetin  treatment,  which  had  not  at  that  time  been  discovered. 
With  such  treatment  a  speedy  recovery  might  have  been  expected. 


\ 


CHAPTER  Vm 

SWELLING  OF  THE  FACE 

First  of  all,  it  should  be  recognized  that  a  certain  amount  of 
swelling  about  the  eyes  and  a  trifling  pufhness  of  the  rest  of  the  face 
is  normal  in  certain  individuals  when  they  first  wake  in  the  morning. 

Doubtless  there  are  individual  differences  of  tissue  which  explain 
why  some  people  have  this  symptom  and  others  do  not.  Nothing  is 
more  striking  than  the  individual  differences  between  healthy  people 
as  regards  the  dryness  or  juiciness,  the  firmness  or  fiabbiness  of  their 
tissues.  Fat  people  are  perhaps  a  little  more  apt  to  have  this  symp- 
tom (early  morning  edema  of  the  face)  than  others. 

After  an  alcoholic  debauch  persons  who  never  suffer  from  this 
symptom  at  other  times  often  present  it  in  a  marked  degree.  Just 
why  I  do  not  know. 

During  pregnancy  a  certain  amount  of  edema,  both  in  the  face 
and  elsewhere,  is  not  infrequently  seen,  despite  a  normal  condition 
of  the  kidneys  and  heart.  Such  an  edema,  however,  should  always 
lead  us  to  a  most  searching  investigation  of  the  urine  and  of  the 
precordia. 

Local  skin  lesions,  such  as  severe  sunburn,  eczema,  measles,  and 
erysipelas,  are  associated  with  edema  of  the  face,  sometimes  of  tre- 
mendous degree.  Especially  in  erysipelas  one  often  sees  a  total 
closure  of  both  eyes,  owing  to  the  accumulation  of  fluid  in  the  loose 
tissues  around  them. 

The  familiar  swollen  face  of  toothache  leads,  as  a  rule,  to  no  dif&- 
culties  of  diagnosis,  because  it  is  unilateral  and  because  the  affected 
tooth  calls  attention  to  its  presence  in  unmistakable  ways.  Occa- 
sionally, however,  an  affection  of  the  antrum  or  a  local  abscess  of  the 
cheek  may  accompany  or  simulate  the  edema  of  toothache.  Careful 
examination  should  set  us  right. 

In  glomerular  nephritis,  and  in  some  of  the  degenerative  tubular 
lesions  of  the  kidney,  such  as  corrosive  subHmate  kidney,  marked 
edema  of  the  face  often  precedes  or  exceeds  the  edema  of  other  parts. 
The  vascular  forms  of  nephritis  and  the  more  chronic  slow-going 
types  less  often  produce  facial  edema.     Children  seem  to  be  some- 

VoL.  11—27  417 


4l8  DIFFERENTIAL  DIAGNOSIS 

what  more  subject  than  adults  to  severe  edema  in  connection  with 
nephritis,  and  this  apphes  to  the  face  as  well  as  to  other  parts  of  the 
body. 

Some  years  ago  it  was  customary  to  say  that  cardiac  edema  was 
never  in  the  face,  -while  renal  edema  was  very  apt  to  begin  there. 
This  can  no  longer  be  maintained  in  any  strict  sense,  although  it  repre- 
sents the  truth  as  regards  the  majority  of  cases.  Pure  cardiac  dropsy, 
without  any  nephritis,  may  produce  swelling  of  the  face,  although 
such  swelling  rarely  precedes  or  exceeds  the  dropsy  of  other  parts. 

Of  special  diagnostic  importance  is  the  facial  edema  of  Jrichiniasis, 
first,  because  it  is  often  forgotten,  and  second,  because  we  are  dealing 
here  with  a  disease  which  is  much  less  simple  than  that  of  cardiac  and 
renal  causes  of  edema.  In  trichiniasis  the  puffy  face  accompanies,  as 
a  rule,  a  greater  or  lesser  degree  of  conjunctivitis,  and  the  swollen 
lids  are  often  red,  in  addition.  Should  such  a  group  of  signs  be 
associated  with  any  unexplained  fever,  trichiniasis  should  always  be 
suspected,  whether  the  classical  pains  and  soreness  are  present  or  not. 
When  trichiniasis  is  suspected,  as  it  should  be,  owing  to  conditions 
described  above,  the  next  step  should  always  be  the  examination  of 
the  blood  for  eosinophiha.  If  that  is  present,  trichiniasis  is  almost 
certainly  the  diagnosis,  provided,  of  course,  that  the  renal  and  cardiac 
and  local  dermatologic  causes  of  edema  are  excluded.  If  eosinophiha 
is  absent,  we  cannot  exclude  trichiniasis,  since  there  are  now  and 
then  cases  in  which  this  symptom  is  for  a  long  time  missing.  Where- 
ever  it  is  possible  the  diagnosis  should  be  further  substantiated  by 
histologic  examination  of  a  bit  of  excised  muscle,  or,  failing  this, 
by  the  study  of  the  sediment  of  a  specimen  of  venous  blood,  laked 
with  3  per  cent,  acetic  acid,  according  to  the  methods  suggested  by 
Staiibh^  and  Janeway." 

In  pernicious  anemia  edema  of  the  face  is  much  less  common  than 
swelUng  of  the  lower  extremities.  Nevertheless,  it  is  occasionally 
seen,  especially  in  cases  which  are  being  treated  with  large  doses  of 
arsenic.  How  far  arsenic-poisoning  is  the  cause  of  such  an  edema  it 
is  often  difficult  to  discover,  but  whenever  arsenic  is  being  given  in 
supposedly  therapeutic  doses,  edema  of  the  face  should  make  us  sus- 
pect that  we  are  poisoning  the  patient. 

Tumors  of  the  neck  or  mediastinum  may  interfere  with  the  venous 
return  from  the  head  in  such  a  way  as  to  produce  an  alarming  edema 
of  the  head  and  neck.     Thoracic  aneurysm  may  occasionally  produce 

^Miinch.  med.  Woch.,  1908,  Iv,  2601. 

^  Archives  of  Internal  Medicine,  vol.  iii,  p.  263. 


Swollen  Face 


MORNING  DEBILITY  ^ 

Al  rnHOLmM  >  *^*^^^  """^^   MANY  AND  TOO  VAGUELY  ENUMERABLE  FOR  GRAPHIC 

I         REPRESENTATION. 

TOOTHACHE  ^ 

CHRONIC  NEPHRITIS    H^HiHBIi^HiaHHII^HHH^Hil^^^Hi  506 

ACUTE  NEPHRITIS        ■■■I^^^^^I^HHBH  301 

ERYSIPELAS                     H^^^H^  168 

EPIDEMIC  PAROTITIS   ■i^  64 

TRICHINIASIS                    ^  39 

WHOOPING-COUGH        ■  34 

MYXEDEMA                        ■  27 

TUMORS     OF    THE  I  3 
MEDIASTINUM         J 


SWELLING    OF   THE   FACE  419 

the  same  result.  In  such  cases  the  edema  usually  appears  rather  sud- 
denly, and  is  associated  with  other  pressure  symptoms,  such  as  pains 
or  dyspnea.  Any  reasonably  careful  physical  examination  should 
reveal  the  cause  of  such  an  edema.  Lymphoblastoma  (Hodgkin's 
disease)  is  probably  the  commonest  cause  of  this  type  of  edema. 
Rarer  diseases,  leading  to  the  same  kind  of  venous  obstruction,  are 
thrombosis  of  the  superior  vena  cava  or  one  of  its  main  branches, 
chronic  mediastinitis,  and  angina  ludovici. 

In  myxedema  there  is  often  some  true  edema  accompanying  the 
m}xedematous  enlargement,  whether  in  the  face  or  other  parts  of  the 
body.  Such  cases  are  sometimes  mistaken  for  nephritis,  especially 
if  there  chance  to  be  some  albuminuria  and  cyHndruria. 

Inflammation  of  the  subcutaneous  tissue  due  to  anthrax,  the 
septic  cellulitis  of  insect  bites,  and  actinomycosis  are  rare  causes  of 
facial  edema. 

In  typhus  fever  (Brill's  disease)  a  suffusion  of  the  conjunctivae 
is  not  infrequently  associated  with  some  edema  about  the  eyes. 
Drug  eruptions,  such  as  an  iodid  of  bromid  rash,  may  be  accompanied 
by  marked  edema  of  the  face. 

Finally,  we  must  always  remember  the  possibiHty  of  an  unex- 
plained edema,  to  which  we  sometimes  give  the  name  of  angioneurotic 
in  an  attempt  to  cover  up  our  ignorance.  All  that  can  be  said  of  this 
variety  of  swelling  is  that  it  may  be  extreme,  may  appear  suddenly, 
and  almost  always  disappears  within  a  few  days. 

Differential  diagnosis  of  the  different  types  just  listed  is  usually 
easy,  provided  we  know  what  to  look  for  and  give  the  time  neces- 
sary to  get  a  good  history  and  to  make  a  thorough  physical  exami- 
nation. 

Case  172 

An  electrician  of  thirty-three  entered  the  hospital  September  lo, 
1907.  The  patient  was  perfectly  well  up  to  two  weeks  ago,  when  he 
began  to  have  pufiiness  and  redness  of  the  face  and  hands,  more 
marked  each  morning,  and  accompanied  by  frontal  headache.  During 
the  past  week  he  has  had  several  chills,  and  sweats  more  than  usual. 
Yesterday  he  had  a  severe  attack  of  vertigo  and  was  for  a  moment 
completely  bhnd.  He  did  not  fall.  He  has  gastric  distress  and 
flatulence  after  meals  and  yesterday  vomited  once.  He  is  very 
nervous,  and  in  the  last  two  weeks  has  lost  8  pounds. 

Physical  examination  showed  good  nutrition,  marked  puffiness 
of  the  face,  in  which  many  muscles  twitch  involuntarily  from  time 


420  DIFFERENTIAL  DIAGNOSIS 

to  time.  This  twitching,  he  said,  was  never  present  until  within 
two  weeks.  The  chest  was  negative,  save  for  a  systolic  murmur  at 
the  apex,  not  transmitted.  The  spleen  was  not  palpable,  abdomen 
negative.  The  .white  cells  were  3400;  hemoglobin,  100  per  cent. 
Blood  normal.  Blood-pressure,  100  mm.  Hg.  Owing  to  the  history 
of  chills  the  blood  was  stained  for  malarial  organisms,  but  none  were 
found.  At  entrance  everything  seemed  to  point  to  uremia,  but  the 
urine  and  the  condition  of  the  blood-pressure  seemed  to  negative  this. 
He  was  given  a  hot  bath  and  collapsed  twenty  minutes  later.  His 
temperature  when  first  seen  was  102.6°  F.;  pulse,  120.  Both  these 
fell  to  normal  the  next  morning  and  remained  so  throughout  the  day. 
On  the  14th  the  temperature  again  rose,  as  it  had  on  the  12th. 

Discussion. — The  history  of  this  case  gives  us  no  certain  clue  to 

diagnosis.     The  morning  headache,  with  puffy  face,  twitching,  and 

L/  -^  temporary  blindness,  hints  strongly  at  a  nephritis,  but  the  negative 

'     ■  H.   condition  of  the  urine  and  blood-pressure  enable  us  to  rule  this  out 

^-^ci}  with  reasonable  certainty. 

^     /  /  •    The  type  of  fever  is  very  unlike  that  of  trichiniasis,  and  we  have 
^  *  no  pain  and  no  blood  changes  characteristic  of  that  disease. 

Since  we  note  that  the  patient  had  fever  on  the  loth,  the  12th, 
and  the  14th  of  September,  we  at  once  think  of  malaria.  Neverthe- 
less, it  should  be  remembered  that  tuberculosis  or  septicemia  occa- 
sionally produce  a  tertian  type  of  fever.  Only  by  careful  blood  ex- 
amination can  the  possibility  of  malaria  be  settled.  I  recently  saw  a 
case  of  tuberculous  peritonitis  in  which  the  fever  was  strikingly  like 
that  of  tertian  malaria. 

Outcome. — On  the  14th  a  considerable  number  of  malarial  para- 
sites were  found.  Under  quinin  the  symptoms  all  promptly  disap- 
peared, and  by  the  20th  he  was  well. 

Remarks. — How  does  the  malaria  account  for  the  swelling  of  this 
patient's  face  and  hands?  I  am  quite  unable  to  answer  the  question 
and  I  have  seen  no  explanation  of  it  in  literature. 

Case  173 

A  shoemaker  of  thirty-three  entered  the  hospital  August  29,  191 1. 
Fourteen  weeks  ago  the  patient  had  toothache  and  swollen  jaw.  A 
dentist  extracted  the  tooth  and  later  lanced  the  jaw  twice.  The  swell- 
ing continued,  and  twelve  weeks  ago  the  jaw  was  again  lanced  and 
poulticed.  Ten  weeks  ago  he  was  in  a  hospital  and  was  operated  on 
for  abscess  of  the  jaw.  The  swelling  was  then  much  reduced,  but  four 
days  ago  again  increased.     At  entrance,  August  29th,  the  whole  face, 


SWELLING   OF   THE   FACE  42 1 

jaw,  and, neck  were  swollen  and  tender,  especially  on  the  right  side. 
There  was  no  definite  fluctuation,  save  about  a  small  ulcer  in  the 
center  of  the  mass,  where  a  crater-like  depression  was  felt. 

Physical  examination,  including  the  blood  and  urine,  was  other- 
wise negative. 

Discussion. — The  swollen  jaw  is  like  that  accompanying  tooth- 
ache and  due  to  alveolar  necrosis  and  sepsis.  The  history  shows 
that  this  was  the  first  diagnosis  made,  but  the  continuance  of  the 
swelling,  despite  the  dentist's  best  efforts,  makes  us  surmise  that  this 
diagnosis  may  be  wrong. 

In  191 1  the  Esch  bill  prohibiting  the  use  of  phosphorus  in  the 
manufacture  of  matches  had  not  been  passed.  Phosphorus  necrosis 
of  the  jaw  was,  therefore,  a  possibihty  at  the  time  when  this  patient 
was  seen,  but  as  he  had  had  no  dealings  with  phosphorus  this  was 
not  seriously  considered.  Evidences  of  syphiHs  or  tuberculosis  must 
be  looked  for  in  any  lesion  in  this  part  of  the  body. 

In  relation  to  syphilis,  our  best  procedure  is  to  take  a  careful 
history,  do  the  Wassermann  reaction,  and,  if  necessary,  try  the  thera- 
peutic test.  Tuberculosis  can  be  diagnosed  with  any  certainty  only 
by  histologic  examination  of  an  excised  portion.  It  is  not  common 
in  patients  of  this  age  and  in  this  situation.  The  actual  disease 
found  in  the  outcome  would  probably  be  suspected  by  very  few  of  us. 

Outcome. — Operation  showed  a  honeycombed  mass  of  pus  pockets. 
Microscopic  examination  of  the  discharges  showed  the  organism  of 
actinomycosis.  The  patient  left  the  hospital  in  good  condition  on  the 
9th  of  September, 

Case  174 

A  laundress  of  twenty-four  entered  the  hospital  February  22,  1909. 
The  patient's  family  history  and  past  history  excellent,  save  for 
scarlet  fever  seven  years  ago.  She  woke  up  this  morning  to  find  the 
left  side  of  her  face  and  neck  swollen.  She  had  a  slight  headache  and 
the  bowels  did  not  move.  Her  temperature  was  99.5°  F.  Physical 
examination  was  negative,  except  for  swelling  and  tenderness  in  the 
region  of  both  parotids,  especially  the  left. 

Discussion. — What  else  could  this  be  besides  mumps?  Obviously 
we  have  swelling  of  the  glands,  which  are  attacked  by  mumps.  It 
remains  to  inquire  what  else  can  attack  them.  A  septic  parotitis 
not  infrequently  complicates  typhoid  fever,  and  is  sometimes  seen 
as  an  inexplicable  complication  of  peptic  ulcer,  gastric  or  duodenal. 
Suppurative  parotitis  also  occurs  in  acute  and  chronic  endocarditis, 


422 


DIFFERENTIAL   DIAGNOSIS 


in  cerebrospinal  meningitis,  small-pox,  Asiatic  cholera,  yellow  fever, 
and,  rarely,  in  lobar  pneumonia.  Parotitis  complicating  heart  infec- 
tion should  be  regarded  as  part  of  a  general  sepsis,  and  a  similar  in- 
flammation of  the  .parotid  may  be  found  in  other  t^-pes  of  sepsis — for 
example,  hepatic  abscess. 

If  none  of  these  causes  can  be  found,  any  acute  parotitis  should 
be  called  mumps.  If  previous  cases  can  be  discovered  and  their  con- 
tagion proved,  the  diagnosis  is  all  the  more  certain,  but  we  cannot 
always  acquire  such  proof. 

Outcome. — By  the  3d  of  March  the  swelling  was  gone  and  she  was 
allowed  to  go  home,  but  kept  m  isolation  for  ten  days  more. 

Case  175 

An  Italian  barber  of  twenty-five  entered  the  hospital  April  6, 
1909.     Five  days  ago,  while  at  work,  he  noticed  that  his  eyes  were 

swelling  up.  Later,  he  had  a 
severe  headache  and  pains  all 
over  his  body.  The  next  day  he 
remained  in  bed,  had  no  appetite, 
felt  feverish,  nearly  vomited  sev- 
eral times,  and  was  constipated. 

Physical  examination  shows 
good  nutrition,  eyelids  red  and 
swollen,  conjunctivae  much  in- 
jected and  swollen.  At  the  apex 
of  the  heart  is  a  very  harsh 
blowing,  systolic  murmur,  trans- 
mitted to  the  axilla.  No  enlarge- 
ment of  the  organ.  Pulmonic 
second  sound  not  accentuated. 
There  is  slight  tenderness  of  the 
biceps  and  calves;  slight  edema 
of  the  legs.  The  urine  is  nega- 
tive. The  temperature  is  as 
shown  in  Fig.  144.  The  blood  showed  12,300  leukocytes,  26  per 
cent,  of  which  were  eosinophils. 

Discussion. — The  initial  symptoms  are  merely  those  common  to 
many  infectious  diseases  and  peculiar  to  none,  but  the  fever  and 
leukocytosis  associated  with  conjunctivitis,  red  and  swollen  eyelids, 
should  make  us  very  suspicious  of  trichiniasis.  Since  there  is  an 
eosinophilia,  the  diagnosis  is  rendered  almost  certain.     What  should 


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Fig.  144. — Temperature  range  in  Case  175. 


SWELLING   OF   THE   FACE  423 

be  said  regarding  the  cardiac  murmur?  In  my  opinion,  it  is  explained 
merely  by  the  fever  and  represents  simply  one  manifestation  of  the 
general  infection.  On  the  other  hand,  it  is  quite  conceivable  that  the 
murmur  may  represent  the  effects  of  some  previous  endocarditis. 
The  question  can  be  decided  by  following  the  condition  of  the  heart 
after  the  fever  has  subsided. 

Outcome. — On  the  12th  of  April  the  eosinophilia  had  fallen  to 
13  per  cent.,  at  which  point  it  remained  April  14th.     About  30  drops 


Fig.  145. — Embryo  of  Trichinella  spiralis  in  blood  laked  with  3  per  cent,  acetic  acid. 
Leukocytes  and  disintegrated  red  cells  also  are  shown  (X  800).  (Reproduced  b}^  kind 
permission  of  Dr.  T.  C.  Janeway,  from  the  Archives  of  Internal  Medicine,  where  it 
appeared  in  April,  1909.) 

of  blood  were  squeezed  out  of  the  ear  into  acetic  acid  solution,  then 
centrifugalized,  and  the  sediment  examined.  Two  trichina  embryos 
were  found  in  this  sediment  without  much  difi&culty.  The  patient 
had  practically  no  symptoms  or  signs  except  dull  aching  of  the  muscles. 
This  was  present  as  late  as  the  19th  of  April,  but  he  gained  rapidly 
after  that  date  and  left  the  ward  well  on  the  24th.  It  w^as  later 
learned  that  he  had  eaten  uncooked  sausages  two  weeks  before  the 
beginning  of  this  illness. 


424  DIFFERENTIAL   DIAGNOSIS 

Remarks. — This  method  of  demonstrating  the  trichiniasis  embryo 
is  of  special  importance  when  the  patient  refuses  to  consider  it  a  favor 
for  us  to  take  out  a  piece  of  his  muscle,  or  when  the  investigation 
of  such  a  specimen  is  negative.  In  certain  cases  the  embryo  may  be 
found  in  the  blood  without  a  long  hunt  (Fig.  145). 

Case  176 

On  the  same  day,  the  6th  of  April,  1909,  an  Italian  tailoress  of 
twenty-one  (whose  case  was  in  all  respects  similar  to  that  just  nar- 
rated), was  examined  in  the  same  way  for  trichinae  in  the  blood,  but 
none  were  found.  A  teased  specimen  of  muscle,  taken  from  the  calf, 
serial  sections  of  this  muscle  were  trichina;  finally  found, 
was  then  examined.     It  was  also  negative.     Only  on  examination  of 

Discussion. — This  case  is  inserted  merely  to  show  how  difficult 
it  sometimes  is  to  find  the  trichiniasis  embryo.  The  examination  of 
serial  sections  is  a  task  which  not  every  pathologist  will  undertake. 

Case  177 

A  laborer  of  thirty-two  entered  the  hospital  December  23,  1911. 
About  five  weeks  ago  the  patient  consulted  his  physician  for  swelling 
of  the  right  cheek.  The  physician  made  a  small  incision  and  let  out  a 
cupful  of  pus.  The  cheek  first  looked  like  erysipelas,  and  was  treated, 
after  incision,  with  wicks  and  poultices.  Later,  the  inflammation 
extended  up  toward  the  eye  and  the  cavity  had  to  be  explored  with 
the  finger.  After  this  the  swelling  went  down  under  poultices  and 
the  patient  did  well  until  a  week  ago,  when  the  edema  returned. 
A  dentist  declared  that  the  trouble  did  not  come  from  the  teeth. 
No  general  physical  examination  was  made,  but  an  a;-ray  showed  pus 
in  the  antrum  and  some  bone  necrosis. 

Discussion. — Clearly  we  are  dealing  with  some  suppurative  proc- 
ess in  the  region  of  the  cheek.  It  might  be  a  local  abscess  or  one  orig- 
inating in  a  tooth  or  in  the  antrum.  Careful  local  examination  alone 
can  decide. 

.  As  a  more  remote  possibility,  however,  we  should  remember  that 
tuberculosis,  syphilis,  or  malignant  disease  might  be  accompanied 
with  a  good  deal  of  suppuration,  and  are  sometimes  mistaken  for 
simple  abscess.  In  the  present  case,  however,  the  acute  onset  of  the 
symptoms  and  absence  of  any  deep  inflammation  or  induration  makes 
these  three  diseases  impossible.  It  is  in  the  relatively  chronic  in- 
durated cases  that  the  trio — tuberculosis,  syphilis,  neoplasm — should 
especially  be  borne  in  mind. 


SWELLING    OF    THE    FACE 


425 


Erysipelas,  which  was  considered  here,  is  more  superficial  in  its 
effects  and  the  amount  of  redness  should  be  greater. 

The  case  demonstrates  the  need  of  ic-ray  examination  in  all  doubt- 
ful swellings  about  this  part  of  the  body. 

Outcome. — On  the  2d  of  January,  191 2,  the  wound  was  opened 
and  the  probe  touched  bare  bone  in  the  region  of  the  antrum.  The 
malar  bone  in  the  superior  maxilla  showed  necrosis,  which  was  chiseled 
away  and  a  large  opening  made  into  the  antrum.  On  the  6th  of  Jan- 
uary the  patient  felt  much  better,  though  there  was  still  some  dis- 
charge. As  he  had  had  no  temperature  in  two  weeks'  observation 
he  was  discharged. 

The  patient  reported  at  the  Out-patient  Department,  where  the 
wound  was  treated,  but  January  2 2d  there  was  still  some  edema  of  the 
flap,  with  irregular  intervals  of  pain,  lasting  twenty  to  thirty  minutes. 
On  the  29th  of  January  the  swelling  was  less,  and  careful  examina- 
tion showed  no  reason  to  doubt  the  original  diagnosis. 


Case  178 

A  coachman  of  fifty  entered  the  hospital  October  30,  191 1.  Three 
nights  ago  he  noticed  swelHng  and  tenderness  of  the  right  cheek. 
The  next  morning  it  was  mostly 
gone,  and  that  night  it  reappeared 
and  was  then  accompanied  by  red- 
ness. Yesterday  the  swelling  al- 
most closed  his  right  eye.  He  has 
had  no  pain  and  no  burning  sensa- 
tions. He  attributes  the  trouble 
to  a  bad  second  right  lower  molar, 
which  has  been  tender  for  a  year  or 
two.  His  temperature  has  been 
normal  until  last  night,  when  it 
rose  to  101°  F. 

Physical  examination  is  nega- 
tive, save  for  a  rough-blowing  sys- 
tolic murmur  at  the  apex  of  the 
heart,  transmitted  to  the  axilla, 
a  scar  in  the  appendix  region,  and 
a  marked  swelling  of  the  whole 
right  side  of  the  face,  closing  the 
right  eye.  The  color  was  now  bright  red,  with  a  sharp  border  along 
the  right  side  of  the  nose,  and  in  the  temporal  region  an  area  was 


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Fig.  146. — ^Temperature  range  in  Case  178. 


426  DIFFERENTL\L  DIAGNOSIS 

indurated  and  slightly  hot.  Temperature  was  as  in  Fig.  146.  On  the 
31st  he  had  a  chill  and  his  temperature  rose  to  104.4°  F.  The  right 
ear  was  now.  swollen  and  the  left  side  of  the  face  became  involved. 

Discussion. — In  the  early  stages  of  this  disease,  before  the  sharp 
line  of  demarcation,  the  deep  red  color,  and  the  elevation  of  the 
advancing  margin  have  made  their  appearance,  the  symptoms  might 
be  attributed,  as  in  this  case,  to  a  bad  tooth.  The  true  diagnosis, 
erysipelas,  rests  upon  the  local  features  just  mentioned,  upon  the 
presence  of  marked  constitutional  s^-mptoms,  the  history  of  previous 
attacks,  the  situation  near  the  nose,  eye,  or  ear,  and  the  absence  of 
any  deeper  local  cause  of  suppuration. 

Outcome. — On  the  3d  of  November  the  swelling  was  subsiding,  and 
by  the  7  th  all  redness  and  swelling  were  gone.  He  left  the  hospital 
on  the  nth. 

Case  179 

A  Russian  storekeeper  of  forty-five  entered  the  hospital  January 
6,  1910.  Family  history  negative.  Had  rheumatism  in  his  right  leg 
for  eight  years.  Last  August  he  was  in  a  runaway,  broke  his  left 
forearm  and  injured  his  head.  Denies  venereal  disease.  Is  not  alco- 
holic. 

Five  weeks  ago  his  entire  head  and  the  upper  part  of  his  chest 
became  red,  and  his  head  swelled  up  so  that  he  could  not  see.  This 
was  accompanied  by  a  great  edema  of  the  scrotum.  The  left  hand  and 
fingers  have  been  stiff  since  his  accident,  and  his  right  hand  and  arm 
and  both  legs,  from  the  knees  down,  have  been  gradually  getting  stiff 
for  five  weeks.  They  have  never  been  swollen.  For  three  weeks  he 
has  not  been  able  to  walk.  His  physician  has  no  knowledge  of  any 
spinal  injury.  He  has  had  no  pain,  no  headache  or  backache,  but 
has  lost  28  pounds  since  his  accident  eight  months  ago.  For  the  past 
month  his  sleep  has  been  poor  and  he  has  been  very  nervous. 

At  entrance  there  was  no  fever,  no  edema,  and  physical  examina- 
tion was  altogether  negative.  After  considerable  persuasion  he  was 
enabled  to  walk.  By  the  12th  of  January  he  walked  about  the  ward 
and  received  Zander  treatment.  He  complained  enthusiastically  of 
many  weird  symptoms,  such  as  fever  in  his  teeth,  blood  in  his  belly, 
and  so  forth,  and,  although  he  improved  considerably,  went  home, 
dissatisfied,  on  the  25th. 

Discussion. — This  is  one  of  those  curious  cases  in  which  the 
diagnosis  of  hysteria  or  angioneurotic  edema  represents  the  best  that 
we  can  do,  but  they  never  should  satisfy  us  or  make  us  beheve  that 


SWELLING    OF   THE   FACE  427 

we  have  got  to  the  bottom  of  the  trouble.  Mediastinal  pressure 
was  at  first  suggested  by  the  marked  swelling  of  the  entire  head  and 
upper  chest.  Local  inflammatory  causes  are  excluded  by  the  absence 
of  fever  and  leukocytosis.  The  swelling  of  the  scrotum  makes  it 
clear  that  no  local  pressure  in  the  mediastinum  will  account  for  the 
edema  unless  we  suppose  two  separate  causes. 

There  is  much  in  the  case  to  suggest  a  traumatic  neurosis  or 
traumatic  hysteria,  but  the  interval  of  time  between  the  runaway 
accident  and  the  beginning  of  these  symptoms  seems  sufficient  to 
exclude  this. 

By  the  accumulation  of  negative  evidence  against  the  more  exact 
and  well-known  causes  for  edema,  we  come  down  to  hypotheses  about 
the  vasomotor  system,  hypotheses  such  as  have  been  expounded  at 
length  by  Solomon  Solis-Cohen  in  various  volumes  of  the  ''Trans- 
actions of  the  Association  of  American  Physicians."  Vasomotor 
ataxia,  as  Dr.  Soiis-Cohen  calls  it,  is  perhaps  as  good  a  name  as 
any  for  many  mysterious  symptom  compHcations,  of  which  the 
present  cause  is  an  example. 

Outcome. — Dr.  E.  W.  Taylor  considered  the  case  one  of  hysteria. 

Case  180 

A  Greek  pedler  of  twenty-five  entered  the  hospital  March  21,  19 10. 
He  was  never  sick  until  four  years  ago,  when  he  had  erysipelas.  His 
habits  are  excellent,  and  he  denies  venereal  disease.  Three  weeks  ago 
he  "caught  cold."  Eight  days  ago  his  face  became  swollen  and  the 
next  day  his  feet  also.  At  the  beginning  of  the  illness  he  had  a  chill, 
felt  feverish,  with  slight  headache  and  pains  in  his  legs  and  in  the  soles 
of  his  feet.  His  bowels  have  not  moved  for  four  days.  He  has  had 
several  nosebleeds  and  has  bled  from  his  ears. 

Physical  examination  showed  edema  of  the  face,  legs,  and  feet. 
The  heart's  apex  was  in  the  fifth  space,  2^  cm.  outside  the  nipple,  the 
right  border  5  cm.  in  the  median  line.  Sounds  snapping  in  quaHty, 
aortic  second  accentuated,  no  murmur;  the  pulse  apparently  of  in- 
creased tension  and  notably  slow,  50  to  60.  Systohc  blood-pressure, 
150.  Otherwise  physical  examination  was  negative.  The  urine  aver- 
aged 40  ounces,  slightly  smoky  in  color.  The  specific  gra\dty  was 
1025  on  the  average;  albumin,  1.4  per  cent.  There  were  many  casts, 
mostly  hyaline,  with  varying  amounts  of  fat  and  epithehal  cells  ad- 
herent. The  blood  showed  slight  achromia,  78  per  cent,  hemoglobin, 
no  leukocytes.  In  four  days  the  edema  was  gone,  under  milk  diet, 
daily  hot-air  baths,  and  i  ounce  of  magnesium  sulphate  every  morn- 


428  DIFFERENTIAL   DIAGNOSIS 

ing.  Toward  the  end  of  his  stay  the  edema  persisted  only  in  the 
lungs  and  on  the  top  of  his  head. 

Discussion. — What  else  could  this  be  but  acute  nephritis?  We 
have  the  sudden  appearance  of  edema,  with  evidence  of  infection, 
bleeding  at  the  nose  and  ears,  anemia,  slight  hypertension,  and  the 
classical  urine  of  acute  nephritis. 

I  have  seen  a  classical  picture  much  like  this  in  cerebrospinal 
meningitis,  but  in  that  case  the  brain  symptoms  soon  become  more 
marked.  Nevertheless,  the  diagnosis  of  uremia  was  actually  made 
in  this  case  and  only  the  autopsy  sets  us  right. 

Trichiniasis  would  account  for  the  edema,  the  pains  in  the  legs, 
and  the  evidence  of  infection.  It  is  to  be  excluded  chiefly  by  the 
negative  blood  examination,  the  significant  urinary  findings,  and  the 
course  of  the  case. 

Outcome. — On  the  loth  of  May,  1913,  and  on  the  nth  of  March, 
1914,  he  reported  at  my  request  and  declared  himself  perfectly  well, 
although  it  took  him  a  year  to  recover  his  full  strength.  He  went  to 
work  three  months  after  he  left  the  hospital  and  has  not  had  to  give 
up  since.  At  the  present  time  his  blood-pressure  is  125  mm.  Hg. 
and  his  urine  is  normal. 

Case  181 

A  colored  laundress  of  thirty-three  entered  the  hospital  February  9, 
1 910.  Her  family  history  was  negative.  Five  years  ago  she  had  a 
red  rash  all  over  her  body,  a  severe  headache,  and  falling  of  the  hair. 
Since  that  time  she  has  had  various  skin  lesions  on  her  face.  In 
October,  1909,  she  caught  cold  and  had  a  severe  sore  throat  and 
cough.  She  was  unable  to  swallow  anything  but  milk  and  eggs  on 
account  of  pain  in  her  throat.  She  was  in  bed  four  weeks.  For  the 
past  two  weeks  she  has  been  hoarse,  and  for  ten  days  has  had  diffi- 
culty in  breathing,  with  attacks  of  suffocation,  lasting  ten  to  fifteen 
minutes.  She  weighed  130  pounds  in  October,  106  pounds  in  De- 
cember, 116  pounds  now. 

Physical  examination  was  negative,  save  for  the  evidences  of 
laryngeal  stenosis.  There  was  marked  infiltration  of  the  left  aryten- 
oid and  of  the  left  half  of  the  larynx.  Dr.  H.  P.  Mosher  considered 
the  condition  syphilitic.  The  Wassermann  reaction  was  positive. 
Under  daily  inunctions  of  mercury  and  moderate  doses  of  iodid  of 
potash  the  condition  of  the  larynx  rapidly  improved,  and  on  the  17th 
of  February  the  dyspnea  was  slight.  On  the  2  ist  she  was  out  of  danger 
and  went  home. 


SWELLING   or   THE   FACE 


429 


May  18,  1910,  she  returned,  having  been  at  the  Out-patient  De- 
partment since  her  previous  stay  in  the  hospital,  with  more  or  less 
trouble  all  the  time.  Six  days  ago  she  was  awakened  in  the  night 
with  earache,  toothache,  and  pain  in  the  throat,  and  the  next  morning 
the  whole  throat  was  swollen,  as  it  now  is. 

Physical  examination  showed  the  cardiac  apex  ii|  cm.  from  mid- 
sternum,  2  cm.  outside  the  nipple.  Pulmonic  second  accentuated. 
No  murmur.  An  irregular  area  of  discoloration  was  seen  on  the  out- 
side of  the  right  leg,  from  the  hip  to  the  dorsum  of  the  foot.  The 
whole  face  was  somewhat  swollen.  From  the  right  side  of  the  lower 
jaw,  reaching  down  on  the  neck,  there  was  an  area  of  induration, 
10  by  7  cm.,  very  tender,  and  a  small  area  of  fluctuation  was  made 
out,  anteriorly  to  the  sternomastoid  muscle.  The  temperature 
ranged  as  in  Fig.  147.  Blood-pressure,  112 
mm.  Hg.  Blood  and  urine  normal.  The 
laryngeal  stenosis  was  now  much  less 
troublesome,  and  she  suffered  more  from 
dysphagia  than  from  dyspnea.  She  was 
salivated  and  her  gums  swollen  and  tender. 

Discussion. — The  hoarseness  and  at- 
tacks of  suffocation  following  a  syphilitic 
infection  leave  no  reasonable  doubt  that  at 
the  time  of  the  first  hospital  visit  the  pa- 
tient suffered  from  laryngeal  S3^hilis.  At 
the  time  of  the  second  hospital  visit  we 
have  apparently  a  general  cellulitis,  repre- 
senting one  of  the  transitions  from  the  most 
superficial  type  of  sepsis  (erysipelas)  to  the 
deeper  and  more  localized  infiltrations  of 
pus.  The  facial  edema  in  this  case  is  of  the 
same  type  seen  in  erysipelas.  Presum- 
ably there  is  a  burrowing  of  pus  deep  in  the 
tissues  of  the  neck  and  face,  the  type  of  lesion  often  called  deep  cervical 
abscess  or  angina  ludovici. 

Just  what  connection  there  is  between  this  sepsis  and  the  previous 
syphiKs  I  do  not  know.  Probably  the  syphilis  has  predisposed  the 
patient  to  septic  infection. 

Outcome. — On  the  night  of  the  20th  of  May  an  abscess  broke  some- 
where in  her  throat  and  she  spat  up  pus.  After  that  she  was  more 
comfortable,  and  was  referred  on  the  28th  to  the  Out-patient  Depart- 
ment. 


IL^  j|;grl;9llO|l/l!aU3|JVUjKp7  ZS 

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loo-            ic  J!  IZ  _,  »■ 

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M-                ~                                        -^ 

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m  ^      P                           i 

ISO           A^X«5                       -• 

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so    ^md            L       u45.i.^» 

L'""  i  1  M  1  1  M  M  M  1 

Fig.  147. — Temperatiire  range 
in  Case  181. 


430  DIFFERENTIAL   DIAGNOSIS 

Case  182 

A  letter-carrier  of  forty-six  entered  the  hospital  December  2,  igii. 
The  patient  had  scarlet  fever  in  infancy;  otherwise  he  has  been 
well  and  has  an  excellent  family  history.  Denies  venereal  disease. 
Takes  no  alcohol. 

Eight  days  ago,  while  he  was  driving  his  letter-carriers'  wagon,  he 
got  his  feet  wet,  and  next  morning  his  legs  were  swollen  and  his  eyes 
puffy,  and  he  had  some  shortness  of  breath,  with  a  slight  dry  cough. 
His  appetite,  bowels,  and  sleep  continued  normal.  For  six  months 
he  has  noticed  slight  dimness  of  his  eyesight. 

Physical  examination  shows  heart's  impulse  at  the  sixth  rib, 
2  cm.  outside  the  nipple,  14  cm.  from  median  line.  Aortic  second  was 
accentuated.  Blood-pressure,  180  mm.  Hg.,  systolic;  no  mm.  Hg., 
diastolic.  No  cardiac  murmurs.  Lungs  and  abdomen  negative. 
Slight  edema  of  the  lower  legs  and  ankles.  Wassermann  reaction 
negative.  Urine  40  ounces  in  twenty-four  hours,  with  a  specific 
gravity  of  1020  and  very  slight  trace  of  albumin,  occasional  hyaline 
and  granular  casts,  with  now  and  then  a  red  blood-cell  adherent. 
Throughout  his  stay  in  the  hospital,  which  lasted  until  December 
13th,  he  felt  entirely  well. 

Discussion. — The  history  is  a  good  example  of  the  quite  uncon- 
scious sophistry  whereby  patients  continue  the  ancient  tradition  that 
wet  feet  have  something  to  do  with  kidney  disease.  The  more  one 
studies  the  histories  of  cases  of  this  type,  the  less  one  is  inclined 
to  beheve  that  cold  and  wet  have  any  considerable  part  in  their 
etiology. 

Although  the  onset  is  here  acute,  the  condition  of  the  urine  and 
blood-pressure  makes  it  clear  that  we  are  dealing  with  a  chronic 
nephritis,  possibly  one  that  originated  in  the  scarlet  fever  of  the 
patient's  infancy.  Acute  nephritis  is  a  rare  disease,  and  in  our 
hospital  records  is  steadily  becoming  rarer.  This  means,  of  course, 
that  we  do  not  see  the  patients,  as  a  rule,  during  the  acute  stages  of 
their  disease,  but  only  in  the  acute  exacerbation  of  a  chronic  process 
or  in  the  frankly  chronic  stages  of  the  disease.  Since  blood-pressure 
measurements  have  been  made  a  routine,  most  of  the  cases  formerly 
called  acute  nephritis  are  now  labeled  chronic. 

It  seems  to  me  of  interest  that  this  patient  felt  entirely  well  through- 
out his  illness,  and  would  never  have  sought  medical  advice  but  for 
the  swelling  of  his  face  and  legs,  which  naturally  alarmed  him.  Imagine 
now  that  the  edema  had  been  absent,  as  in  many  cases  of  nephritis 


SWELLING   OF   THE   FACE  43 1 

it  is,  the  patient  would  then  have  had  no  knowledge  of  his  disease 
and  would  not  have  consulted  a  physician.  This  is  presumably  what 
happens  in  the  majority  of  cases  of  acute  nephritis. 

Outcome. — July  6,  1914,  the  patient  writes  that  he  is  feeling 
pretty  well,  working  daily  as  mail  collector,  and  that  his  water  has 
recently  been  examined  and  found  to  be  normal. 


CHAPTER   IX 

HEMOPTYSIS 

The  spitting  of  pure  blood  in  any  considerable  quantity  means 
pulmonary  tuberculosis  in  the  vast  majority  of  cases,  no  matter  what 
other  symptoms  are  or  are  not  present.  We  should  always  assume 
such  a  symptom  to  be  due  to  tuberculosis  until  it  is  proved  to  the 
contrary. 

But  we  must  distinguish  between  the  raising  of  pure  blood  in  con- 
siderable quantity  (a  teaspoonful  or  more)  and  the  raising  of  streaks 
of  blood  mixed  with  mucopurulent  sputum.  Blood-streaked  sputum  is 
often  due  to  other  causes  not  tuberculous,  although  it  may  also  occur 
in  tuberculosis  itself. 

The  commonest  mistake  in  relation  to  true  hemoptysis,  as  above 
defined,  is  the  assumption  that  it  is  not  tuberculous  in  origin  merely 
because  the  lungs  show  no  abnormal  signs  and  the  patient  feels  per- 
fectly well.  This  is  just  what  we  should  expect  in  early  phthisis. 
The  majority  of  cases  of  hemoptysis,  examined  within  a  few  days 
of  the  attack,  show  absolutely  no  signs  in  the  lungs  and  the  patients 
feel  perfectly  well,  but  if  they  go  on  living  and  working  as  before  the 
occurrence  of  the  attack,  tuberculosis  will  probably  show  itself  in  a 
few  months  in  an  unmistakable  form.  This  advance  of  the  disease 
should  be  forestalled  by  putting  the  patient,  immediately  after  the 
hemoptysis,  under  treatment  for  incipient  tuberculosis,  without  wait- 
ing for  absolute  proof  that  the  blood  spitting  is  really  tuberculous  in 
origin. 

Aside  from  the  group  of  cases  just  referred  to  in  which  blood 
spitting  is  the  first  symptom  of  tuberculosis,  and  comes,  as  it  were, 
out  of  a  clear  sky,  there  is  the  much  less  important  group  of  cases 
in  which  blood  is  raised  during  the  advanced  and  obvious  stages  of 
phthisis.  Here  it  is  merely  worth  while  to  say  that  such  blood  spitting 
is  not  necessarily  or  often  a  bad  symptom.  The  patient  need  not  feel 
that  he  is  any  worse  after  it  or  by  reason  of  it,  for  occasionally  a  large 
hemoptysis  leads  straight  on  to  acute  tuberculous  pneumonia  and  a 
rapidly  fatal  termination,  but  in  the  vast  majority  of  cases  the  patient 
is  as  well  within  ten  days  after  the  hemoptysis  as  he  was  before  it. 
432 


Causes  of  Hemoptysis  in  Prussian  Soldiers 


TUBERCULOSIS  ■■^■i^^^^lHIHHii^HHHHIIH^^^H  848 

TRAUMA  ■  11 

PNEUMONIA  ■  7 

HEART  DISEASE  ■  5 

BRONCHIECTASIS  I  4 

INFLUENZA  I  3 

SYPHILIS  I  3 

ABSCESS  AND  GAN- 
GRENE OF  THE 
LUNG 


HYDATID   CYST   OFl 
THE  LUNG 

IRRITATING    FUMES 
INHALED 


I    ' 


(F.  Strieker,  Festschrift  zur  loo-Jahrigen  Stiftungsfeier  des  Med.  Chirurg.  Friedrich- 
Wilhelms-Instituts,  page  183.) 


Causes  of  Hemoptysis 


MASSACHUSETTS  GENERAL    HOSPITAL 


^^■■■■■■^^■I^^HIi^^^^^^  1723 
MITRAL  DISEASE  ^I^HBIHI^^HHHHIB^Hl  1177 


UNSPECIFIED  CAUSE  ^^mUM  183 

■■IH  141 


PULMONARY    THROM- 
BOSIS OR  EMBOLISM 


PULMONARY  ABSCESS  \ 
OR  GANGRENE  i 


77 


BRONCHIECTASIS  ^H  ,                                                              58 

PNEUMONIA  Hi  52 

ANEURYSM  ■  22 

TRAUMA  I  17 

NEOPLASM  I  6 


Vol.  11—28  453 


434  DIFFERENTIAL   DIAGNOSIS 

Next  to  pulmonary  tuberculosis,  but  a  very  poor  second  in  relation 
to  it,  comes  pulmonary  infarct  as  a  cause  of  hemoptysis.  Pulmonary 
infarct  is  usually  the  result  of  mitral  disease,  but  may  occur  in  any 
type  of  heart  disease  with  failing  compensation.  It  is  generally  recog- 
nized without  dif^culty,  because  of  the  presence  of  a  well-marked  heart 
lesion  and  of  preceding  or  coincident  symptoms  of  pulmonary  enlarge- 
ment (cough,  dyspnea,  orthopnea,  scattered  rales,  hydrothorax).  Oc- 
casionalh'  both  phthisis  and  mitral  disease  occur  at  the  same  time. 
It  may  then  be  very  difficult  to  decide  which  is  the  cause  of  the 
bleeding. 

In  the  United  States  there  are  no  other  common  causes  of  hemop- 
tysis. All  the  chronic  diseases  of  the  lung,  such  as  bronchiectasis, 
abscess,  gangrene,  neoplasm,  syphilis,  may  in  exceptional  cases  produce 
hemoptysis,  but  the  total  number  of  such  cases  is  very  small.  This 
is  well  shown  in  diagram,  p.  433.  In  Japan  the  parasitic  lung  fluke  is 
a  not  infrequent  cause  of  hemoptysis,  and  upon  our  Pacific  coast  Japan- 
ese immigration  has  now  made  this  type  of  hemoptysis  a  possible  ex- 
perience for  physicians  in  that  part  of  the  country. 

Thoracic  aneurysm  is  not  infrequently  associated  with  hemop- 
tysis. This  is  usually  a  result  of  congestion  of  the  tracheal  wall 
through  direct  pressure  of  the  aneurysm  outside.  Less  frequently 
it  is  due  to  an  actual  leaking  of  the  aneurysm  itself  through  a  per- 
foration in  the  tracheal  wall.  Luckily  for  all  concerned,  it  is  rare  to 
see  an  aneurysm  kill  by  suddenly  bursting  into  the  respiratory  tract. 

Small  amounts  of  blood,  occurring  in  streaks  or  mixed  diffusely 
with  mucopurulent  sputum,  are  frequently  seen  in  patients  who 
smoke  excessively  and  have  acquired  the  habit  of  hawking  to  remove 
pharyngeal  secretions.  Such  actions  now  and  then  scratch  and  irri- 
tate the  throat  enough  to  produce  a  streak  of  blood.  Obviously, 
anything  else  that  makes  the  patient  cough  or  hawk  violently  may 
give  us  blood-streaked  sputum  in  the  same  way. 

Occasionally  an  unhealthy  condition  of  the  gums,  with  or  without 
an  obvious  stomatitis,  produces  the  same  result,  and  all  hemorrhagic 
diseases,  such  as  purpura,  scurvy,  leukemia,  may  show. blood  in  the 
sputum  as  well  as  elsewhere. 

Case  183 

A  bell-boy  of  seventeen  entered  the  hospital  July  13,  1908.  The 
patient's  father  died  of  erysipelas  four  and  one-half  years  ago.  All 
the  other  members  of  his  family  are  well.  There  is  no  tuberculosis 
in  the  family.     The  patient  had  measles  when  three  years  old,  scarlet 


HEMOPTYSIS  435 

fever  at  four,  immediately  followed  by  whooping-cough.  Last  summer 
he  was  sick  for  three  weeks  with  pain  in  the  left  chest,  fever,  cough, 
and  hemoptysis.  Last  winter  he  was  in  bed  three  weeks  with  a 
similar  trouble.    Two  years  ago  he  weighed  93  pounds;  now,  85  pounds. 

For  a  month  he  has  been  in  bed  with  pain  in  the  front  of  the  left 
chest,  worse  on  deep  breathing.  Three  times  in  this  month  he  has 
raised  about  half  a  cupful  of  blood,  and  between  these  times  he  has 
raised  a  small  amount  of  thick,  greenish-yellow  sputum.  He  has  had 
fever  without  chills.  As  long  as  he  can  remember  he  has  had  dysp- 
nea and  palpitation,  but  has  been  otherwise  well. 

Physical  examination  showed  poor  nutrition,  pallor,  normal  pupils, 
glands,  and  reflexes.  The  heart's  impulse  seen  and  felt  in  the  fifth 
interspace,  nipple  line,  3  inches  from  midsternum.  Right  border  of 
dulness  |  inch  from  midsternum.  At  the  apex  there  was  a  presystolic 
thrill,  and  a  long,  rough  presystolic  murmur,  ending  in  a  sharp  first 
sound.  There  was  no  second  sound  at  the  apex,  its  place  being  taken 
by  a  short,  diastolic  murmur.  Just  inside  the  apex  both  these  mur- 
murs were  more  distinct.  The  pulmonic  second  sound  was  accen- 
tuated. Physical  examination  was  otherwise  negative.  No  tem- 
perature in  a  week's  observation.  Urine  negative.  Hemoglobin 
70  per  cent.,  stained  specimen  showing  moderate  achromia.  The 
sputum  showed  no  tubercle  bacilli.  Tuberculin  was  injected  sub- 
cutaneously — on  the  i6th,  f  mg.;  on  the  i8th,  5  mg.;  on  the  20th, 
10  mg.  No  reaction  followed.  The  patient's  family  physician  states 
that  he  was  a  blue  baby. 

He  did  well  while  in  the  ward,  and  left  on  the  21st,  having  gained 
4  pounds  in  the  week.  On  the  15th  of  February,  1909,  he  returned 
to  the  hospital,  having  felt  well  until  he  got  into  a  fight  with  the  cook 
at  the  Waverley  Convalescent  Home  and  was  chased  about  and  had 
to  be  put  to  bed.  He  soon  recovered  and  went  back  to  work.  Two 
months  ago,  after  a  heavy  day's  work,  he  began  to  cough  and  raised 
about  a  wineglassful  of  blood.  That  night  he  had  marked  orthopnea. 
After  about  two  weeks  of  rest  he  went  back  to  work  again,  though 
still  short  of  breath,  but  after  a  day  and  a  half  he  had  to  give  up  on 
account  of  dyspnea  and  pain  in  the  chest.  These  symptoms  have 
continued  ever  since  and  been  associated  with  indefinite  pains  about 
the  right  knee.  There  has  been  no  hemoptysis  for  a  month,  but  the 
cough  has  been  rather  persistent.  His  weight  is  now  93  pounds. 
Appetite  and  bowels  in  good  condition;  sleep  disturbed  by  headaches. 

At  this  time  the  heart's  apex  extended  i^  cm.  outside  the  nipple 
line  and  the  dulness  extended  3  cm.  to  the  right  of  midsternum. 


436  DIFFERENTIAL   DIAGNOSIS 

The  auscultatory  conditions  are  shown  in  Fig.  148.  The  heart 
was  regular.  Pulmonic  second  accentuated  and  doubled.  The 
lungs  showed  at  entrance  high-pitched  squeaks,  scattered  in  each 
lung,  otherwise  physical  examination  is  normal,  including  the  blood 
and  urine.  There  was  no  temperature  in  two  weeks'  observation. 
The  boy  gained  5  pounds.  Under  rest,  magnesium  sulphate,  | 
ounce  in  concentrated  solution,  tincture  of  digitalis,  5  minims 
four  times  a  day,  and  an  occasional  dose  of  aspirin,  10  gr.,  the 
boy  rapidly  recovered,  and  by  February  26th  was  ready  to  go  home. 
Lungs  entirely  negative. 

He  re-entered  the  hospital  for  the  third  time  March  3,  1909,  only 
five  days  from  the  time  when  he  last  left  it.     March  ?d,  while  dressing, 


lll'-i->"""^l^ 


III    I iiiiiil 


SOWK^. 


I      SmukA  lrK^^r\.^ 


i    lliiii..  I    ill 


hrirUL\tv»*4.  Irt,  IMWAWmR. 

Fig.  148. — Diagram  of  heart  sounds  in  Case  183. 

he  began  to  cough  up  blood.  It  appeared  at  this  time  that  the 
patient's  mother  is  a  drunkard,  that  there  is  much  trouble  at  home, 
and  that  the  boy  himself  takes  some  whisky.  This  time  the  heart 
was  irregular,  and  there  was  some  arthritis  of  the  ankles.  He  re- 
mained in  the  hospital  five  weeks  and  gained  12  pounds.  On  the  6th 
of  March  he  spat  up  a  cupful  of  fresh  blood.  Immediately  after 
this  the  breathing  was  harsh  and  noisy  throughout  the  left  chest, 
feeble  throughout  the  right,  and  accompanied  by  crackles.  In  the 
right  axilla  the  heart's  sounds  were  very  loud.  The  raising  of  blood 
continued  until  the  nth.  At  this  time  a  capillary  pulse  and  sugges- 
tion of  Corrigan  pulse  were  noticed,  and  he  had  a  good  deal  of  pre- 
cordial pfiin,  increased  by  exertion.     The  diminished  breathing  in  the 


HEMOPTYSIS 


437 


right  lung  was  still  present  March  30th,  but  no  other  abnormalities 
were  detected. 

November  4,  1909,  he  entered  for  the  fourth  time,  having  been  at 
work  in  July  and  August  as  a  bell-boy.  Three  weeks  ago  he  began  to 
have  hemoptysis  as  before,  and  has  had  four  hemorrhages,  about  a 
cupful  at  a  time.  For  the  last  two  days  he  has  been  very  feverish, 
ached  all  over,  and  had  urgent  dyspnea.  The  heart's  impulse  is  now 
4  cm.  outside  the  nipple  Hne,  right  border  5  cm.  from  midsternum. 
Otherwise  his  condition  is  practically  the  same  as  before,  except  for 
evidence  of  scabies.  The  temperature 
is  as  in  Fig.  149.  Blood  and  urine 
normal. 

Discussion. — The  condition  of  the 
heart  is  typical  of  mitral  stenosis,  and 
under  observation  the  patient  had  more 
than  one  attack  of  arthritis,  presumably 
of  the  rheumatic  or  streptococcic  type. 
There  have  been  no  signs  in  his  lungs  but 
such  as  might  have  been  accounted  for 
by  passive  congestion,  the  result  of  his 
mitral  disease.  The  surprising  thing  is 
that  he  should  have  so  many  attacks  of 
hemoptysis  without  other  signs  of  failing 
compensation.  It  is  also  somewhat  re- 
markable that  he  should  have  fever  and 
pain  in  the  chest  with  each  of  his  attacks, 
yet  this  might  be  explained  as  a  protein 
fever  due  to  absorption  of  blood-clot  in 
the  infarcted  lung. 

During  his  stay  in  the  Massachusetts  General  Hospital  we  did 
our  best  to  discover  any  evidence  of  tuberculosis.  No  bacilH  could 
ever  be  found  in  the  sputum,  and  no  reaction  followed  the  injection  of 
a  large  dose  of  tuberculin.  His  prompt  gain  in  weight  and  strength, 
under  conditions  not  especially  favorable  for  tuberculous  lungs,  also 
argued  against  the  existence  of  any  phthisis,  yet  his  cough  persisted 
in  a  rather  inexplicable  way.  My  diagnosis  was  of  mitral  stenosis 
with  regurgitation,  without  lung  disease.  No  doubt  was  enter- 
tained upon  this  point  when  he  left  my  wards. 

Outcome. — February  i,  191 1,  he  came  to  the  Municipal  Hospital 
for  Tuberculosis,  in  Burroughs  Place,  Boston,  and  there  a  very  differ- 
ent family  history  was  obtained.     He  stated  that  his  step-father 


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in  Case  183. 


438  DLFFERENTL\L   DIAGNOSIS 

died  of  pulmonary  tuberculosis  a  year  previous,  that  is,  a  year  after 
he  left  the  Massachusetts  General,  and  a  sister  of  the  same  disease  two 
years  ago,  the  same  year  in  which  he  left  us.  An  examination  made 
by  Dr.  N.  K.  Wood  showed  extensive  signs  in  both  lungs — namely, 
dulness,  bronchovesicular  breathmg,  increased  fremitus,  and  a  few 
rales  from  the  top  of  each  lung  to  the  midscapular  behind  and  third 
rib  in  front.  The  sputum  was  examined  and  reported  as  positive  for 
tubercle  bacilU.  February  16,  191 1,  he  was  admitted  to  the  Mattapan 
IMunicipal  Hospital  for  Tuberculosis  and  discharged  April  7,  191 1,  with 
a  diagnosis  of  "mitral  stenosis,  probably  not  tuberculous."  At  this  time 
the  signs  were  diffuse  upon  the  left  and  absent  upon  the  right  side. 
Three  negative  sputum  examinations  were  recorded. 

He  re-entered  this  hospital  on  the  12th  of  July,  191 2,  and  stayed  a 
month.  After  2  mg.  of  tuberculin  O.  T.  his  temperature  rose  to 
100.8°  F.  The  local  and  constitutional  reactions  were  considered 
typical.  Except  for  this  fever,  however,  he  had  no  other  rise  of 
temperature.  The  physical  examination  showed  rather  more  definite 
signs  at  the  left  apex. 

On  the  7th  of  August,  191 2,  Dr.  S.  W.  Ellsworth  a:-rayed  his  chest 
at  the  Boston  City  Hospital,  and  reported  extensive  changes  involv- 
ing the  upper  two-thirds  of  each  lung  and  interpreted  as  tuberculous. 
In  view  of  this,  the  discharge  diagnosis,  August  15,  1912,  was  "tuber- 
culosis with  mitral  stenosis.'^  Later  he  went  to  Utica,  New  York. 
In  April,  1913,  a  letter  from  a  friend  of  his  states  that  "his  health  is 
just  about  the  same."  The  records  of  the  Associated  Charities  states 
that  he  lost  another  brother  of  tuberculosis  in  191 2.  On  the  whole, 
the  diagnosis  must  remain  in  doubt,  but  I  am  inclined  to  believe  that 
he  had  both  tuberculosis  and  mitral  stenosis. 

Case  184 

A  plate-printer  of  twenty-one,  born  in  Russia,  entered  the  hospital 
December  18,  1909.  The  patient's  father  died  of  cancer  at  fifty-six; 
otherwise  his  family  history  and  past  history  are  good. 

Three  years  ago  he  began  to  cough.  Eight  days  ago,  after  strain- 
ing himself  with  Hfting,  he  began  to  raise  blood  and  has  raised  it 
every  day  for  the  past  week,  the  amount  being  |  cupful  three  days  ago 
in  the  morning  and  a  hke  amount  this  morning.  He  has  lost  no 
weight,  has  never  coughed  up  blood  before,  has  an  excellent  appetite, 
no  pain,  and  feels  generally  well. 

Physical  examination  shows  good  nutrition  and  is  otherwise  nega- 
tive save  as  relates  to  the  left  lung,  at  the  apex  of  which  there  is  sUght 


HEMOPTYSIS 


439 


Fig.  150. — Chest  signs  in  Case  li 


Fig.  151. — Chest  signs  in  Case  184. 


dulness,  bronchovesicular  breathing,  increased  voice,   and  fremitus 
extending    down    to    the    second    rib    (Figs.    150    and    151).      The 


440 


DIFFERENTIAL  DIAGNOSIS 


temperature  as  in  Fig.  152.  Blood  and  urine  normal.  The  sputum 
was  examined  eight  times  and  no  tubercle  baciUi  found  except  in  one 
small  mass  on  the  23d  of  December,  when  the  organisms  were  seen  in 
very  small  numbers.  Five  examinations  after  that  showed  no  bacilli. 
Discussion. — Sudden  hemoptysis  in  good  health  at  the  age  of 
twenty-one  generally  means  phthisis.  This  assumption  is  verified 
by  the  physical  signs  present  at  the  top  of  the  left  lung.  Such  signs 
would  have  been  of  no  special  significance  had  they  occurred  at  the  top 
of  the  right  lung.    Their  association  with  the  slight  fever  shown  in  Fig. 

152  makes  them  sufficient  evidence  for  a 
presumptive  diagnosis  of  phthisis. 

The  sputum  examination  would  seem 
to  settle  the  matter  beyond  doubt,  but  I 
cannot  feel  quite  certain  upon  this  point. 
When  the  laboratory  observer  reports 
tubercle  bacilli  present  he  should,  in  strict- 
ness, say  "acid-fast  bacilli,  having  the 
usual  morphology  of  tubercle  bacilH."  It 
has  been  shown  in  recent  years  that  other 
acid-fast  organisms  besides  the  tubercu- 
lous are  not  very  uncommon  (streptothrix 
group). 

In  doubtful  cases  we  should  be  more 
ready  to  make  sputum  inoculation  into 
animals.  Nevertheless,  it  seems  to  me 
there  is  no  very  great  doubt  that  this  pa- 
tient has  tuberculosis.  He  has  none  of  the 
other  well-known  causes  of  hemoptysis, 
and  there  is  no  other  disease  of  anything  like  the  same  common- 
ness which  could  explain  his  symptoms. 

Outcome. — The  hemoptysis  ceased  on  the  29th.  It  began  again 
on  the  loth  of  January  and  continued  until  the  i6th,  and  in  small 
quantities  off  and  on  after  that.  He  gained  25  pounds  during  his  three 
months'  stay  in  the  ward,  A  few  rales  were  heard  over  the  affected 
area,  January  2 2d,  February  5th,  and  February  19th.  March  14th 
he  went  to  Rutland  Sanitarium.  In  a  letter,  sent  April  20th,  1913,  the 
patient  states  that  he  is  feeling  fine  and  is  at  work. 


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Case  185 
A  clerk  of  twenty-one  entered  the  hospital  March  16,  19 10.     A 
week  ago  the  patient  felt  tired,  feverish,  and  short  of  breath.     The 


HEMOPTYSIS 


441 


Fig.  153. — Chest  signs  in  Case  185. 


Fig.  154. — Chest  signs  in  Case  185. 


next  day,  Thursday,  he  began  to  vomit  and  continued  for  three  days. 
On  Friday  he  began  to  raise  bloody  sputa,  had  a  pain  in  the  right  side 


442 


DIFFERENTL\L   DL\GNOSIS 


^4^^^ 


of  his  chest,  and  an  eruption  Hkc  cold  sores  on  his  eyelids  and  about 
his  nostrils. 

Physical  examination  shows  fair  nutrition.  Heart's  impulse  extends 
I  cm.  outside  the  nipple,  in  the  fifth  space;  heart  otherwise  negative. 
Lungs  as  in  Figs.  153  and  154.  The  abdomen  is  negative  save  that 
the  liver  dulness  extends  8  cm.  below  the  ribs,  where  a  tender  edge  was 
indistinctly  felt.  Temperature  as  seen  in  Fig.  155.  The  blood  showed 
at  entrance  18,000  luekocytes,  and  on  the  26th,  20,500.     The  urine 

showed  a  slight  trace  of  albumin  and  an 
occasional  granular  cast;  otherwise  nega- 
tive. On  the  26th  the  patient  seemed 
perfectly  well,  and,  in  spite  of  his  high 
leukocyte  count,  he  was  discharged  to  the 
Convalescent  Home. 

Discussion. — The  hemoptysis  in  this 
case  began  with  all  the  evidences  of  acute 
infection,  especially  the  vomiting  and  the 
herpes.  The  heart  showed  evidence  of  di- 
latation, perhaps  from  infectious  weaken- 
ing of  the  muscle ;  the  lung  signs  are  on  the 
right  side,  and  may  account  wholly  or  in 
part  for  the  position  of  the  liver,  8  cm.  be- 
low the  ribs.  The  physical  signs  are  those 
of  solidification,  and  the  remaining  ques- 
tion is  whether  we  are  dealing  with  a  tuber- 
culous pneumonia  or  an  ordinary  pneumo- 
coccus  infection  of  the  lung.  These  two 
diseases  are  notoriously  difficult  to  distinguish,  at  times  actually  im- 
possible, until  we  have  been  able  to  follow  the  case  for  a  number  of  days 
or  even  weeks.  Since  the  pneumonic  signs  of  the  two  diseases  may  be 
identical,  diagnosis  depends  upon  the  question  whether  tubercle  bacilli 
later  appear,  and  whether  the  lung  signs  clear  up  as  they  ordinarily  do 
in  pneumonia  or  persist  as  they  do  in  phthisis.  The  persistence  of 
leukocytosis  suggests  either  a  tuberculosis  or  a  developing  empyema 
or  an  unresolved  pneumonia;  but,  as  the  physical  signs  were  negative 
at  the  time  of  his  discharge,  we  threw  out  all  these  possibiHties  and 
considered  him  well  in  spite  of  his  leukocytosis. 

Outcome. — April  16,  1913,  the  patient  writes  that  he  is  perfectly 
well,  and  has  been  so  since  he  left  the  hospital.  In  view  of  this  outcome, 
we  may  feel  confident  that  a  leukocytosis  in  itself  is  no  reason  for  keep- 
ing a  patient  in  the  hospital  in  the  fear  that  an  empyema  may  develop. 


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-Chart  of  Case  185. 


HEMOPTYSIS 


443 


Remarks. — Why  do  certain  cases  of  pneumonia  begin  with  hemop- 
tysis instead  of  the  ordinary  rusty  sputum?  No  answer,  so  far  as  I 
am  aware,  has  ever  been  given. 

Case  186 

A  housewife  of  twenty-three,  with  a  good  family  history  and  past 
history,  entered  the  hospital  March  2,  191 2.  Three  weeks  ago  the 
patient  began  to  lose  appetite.  Two  weeks  ago  she  felt  a  little  weak, 
but  still  worked  steadily.  Eight  days  ago,  while  at  work,  she  raised 
several  mouthfuls  of  bright  blood.     Since  then  she  has  had  slight 


Fig.  156. — Chest  signs  in  Case  186. 

morning  cough,  with  a  constant  sputa,  headache,  and  fever,  ranging 
between  101°  and  103°  F.  She  has  had  no  pain,  dyspnea,  or  sweats. 
She  has  lost  no  weight. 

Physical  examination  showed  fair  nutrition,  moderate  cyanosis, 
rapid,  shallow  breathing,  physical  signs  as  in  Figs.  156  and  157.  Ex- 
amination was  otherwise  negative.  The  crackles,  March  2d,  were  very 
extensive  and  very  coarse.  Through  and  behind  them  evidence  of 
solidification  was  clear  in  the  left  front,  but  hardly  any  in  the  corre- 
sponding situation  behind.  The  number  of  white  cells  was  never 
elevated,  March  2d  being  9000;  March  7th,  8000;  March  14th,  10,000. 


444 


DIFFERENTIAL  DIAGNOSIS 


CracVles 


Fig.  157. — Chest  signs  in  Case  186. 

Hemoglobin,  90  per  cent.     Urine  normal.      Systolic  blood-pressure, 
no.    Temperature  as  seen  in  Fig.  158.    On  the  2d  of  March  I  thought 

the  case  more  probably  pneumonia 
than  tuberculosis,  but  on  the  nth 
tubercle  bacilli  were  found  in  abun- 
dance in  the  sputum,  and  the  patient 
was  transferred  on  the  15  th  to  the 
Somerville  Hospital. 

Discussion. — This  case  makes  a 
good  contrast  with  that  last  dis- 
cussed. The  onset  and  the  pneu- 
monic signs  are  not  much  different. 
The  low  white  count,  however,  in  a 
patient  not  desperately  ill,  makes 
tuberculosis  more  probable  than  in 
the  last  case.  Nevertheless,  the 
diagnosis  could  not  be  other  than 
pneumonia  until  the  sputum  ex- 
amination finally  changed  it  to  tu- 
berculosis. 

The  point  of  special  interest  is  that  the  patient  worked  steadily 
until  eight  days  ago,  and  had  no  illness  at  all  until  three  weeks  ago. 


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HEMOPTYSIS  445 


Case  187 


A  sign  painter  of  thirty-seven  entered  the  hospital  April  15,  1910. 
The  patient  has  one  sister  now  sick  with  tuberculosis;  otherwise  his 
family  history  is  good.  He  had  bronchitis  when  sixteen,  pneumonia 
at  twenty-two,  syphilis  at  twenty-nine,  ''rheumatism"  at  thirty-two. 
He  has  always  been  very  nervous.  He  has  been  a  hard  drinker  for 
ten  years,  averaging  three  whiskies  and  six  beers  a  day;  twenty 
cigarettes  a  day.     Six  weeks  ago  he  caught  cold,  and  felt  weak  and 

I  in..t . I  lliw  I e^ 

Tig.  159. — Heart  sounds  at  the  apex. 

tired.  Thirteen  days  ago  he  began  to  cough  and  have  pain  in  both 
sides  of  his  chest.  Five  days  ago,  while  working,  he  coughed  up  a 
mouthful  of  bright  blood  and  ever  since  then  has  raised  blood  and 
greenish  material,  i  or  2  ounces  a  day.  At  the  same  time  that  the 
cough  began  he  became  short  of  breath,  especially  at  night,  when  he 
needs  two  pillows.  He  gave  up  work  eleven  days  ago.  He  has  lost 
8  pounds  in  three  months. 

On  physical  examination  the  patient  was  well  nourished,  pupils 
irregular  and  reacting  slowly  to  light;  tongue  tremulous,  brown  coated; 

llnir.„illllllllriilllllili.    ^iTT 

Fig.  160. — Heart  sounds  at  the  third  left  interspace.  The  point  "ist"  indicates  that 
part  of  the  cardiac  cycle  where  the  first  heart  sound  should  be.  No  first  sound  is  heard. 
The  murmur  is  continuous,  with  a  systolic  accentuation. 

general  enlargement  of  the  lymph-nodes.  The  apex  impulse  was  not 
seen,  but  was  felt  in  the  fifth  space,  3^  cm.  outside  the  nipple  line, 
13I  cm.  from  midsternum.  At  the  apex  a  late  systolic  murmur  was 
audible  (Fig.  159).  In  the  left  third  interspace,  near  the  sternum, 
was  a  continuous  murmur  and  thrill,  with  a  systolic  accentuation 
(Fig.  160).  No  heart  sounds  were  audible  in  this  situation.  On 
the  right  side  of  the  sternum,  in  the  fifth  space,  a  ringing  second 
sound  could  be  heard,  which  grew  fainter  toward  the  base  of  the  heart. 
There  was  no  pericardial  friction,  but  many  rubs,  squeaks,  and 
crackles,  scattered  over  both  fronts.     By  percussion  the  heart  seemed 


446  DIFFERENTIAL  DIAGNOSIS 

considerably  enlarged  to  the  right  of  the  sternum.  Systolic  blood- 
pressure  was  115.  The  systolic  portion  of  the  murmur  above  de- 
scribed was  audible  over  the  greater  part  of  the  back,  especially  on  the 
right  side.  The  backs  of  the  lungs  showed  scattered  squeaks  and 
crackles,  similar  to  those  heard  in  front,  but  there  was  no  evidence  of 
fluid  or  solidification.  The  patient  showed  no  fever  in  three  weeks' 
observation.     Blood  and  urine  normal.     Four  examinations  of  the 

blood-stained  sputa  showed  no  tubercle 
bacilli  and  nothing  of  note. 

By  the  27th  the  rales  had  disap- 
peared from  the  chest  and  the  patient 
was  quite  comfortable.  At  this  time 
x-ray  (Fig.  161)  showed  that  the  heart 
was  not  enlarged. 

Discussion. — S}phiHs,  rheumatism, 
alcoholism,  and  possibly  plumbism  are 
Fig.  i6i.-Sketch  on  fluoroscopic     suggested  by  this  patient's  history.     In 

screen.    Tube  at  a  distance  of  7  feet.       f avor  of  tuberculosis  as   a   cause  of  his 

Notice  the  absence  of  any  bulge  on.    hemoptysis  are  the  cough  and  dyspnea, 

the  left  border,  and  its  position  with       .-,       c       •^      ^  •  ,  r  .    1  i      •  1 

,  ,.     ^    ^1      •    ,  the  family  history  01  tuberculosis,  and 

relation  to  the  nipple.  -^  -^  ' 

the  acute  onset  of  the  trouble.  In 
favor  of  syphiHs  are  the  Argyll-Robertson  pupil  and  the  glandular 
enlargement.  The  physical  signs  are  not  characteristic,  though  more 
like  those  of  pulmonary  edema  than  of  any  other  disease. 

With  so  small  a  heart  it  does  not  seem  to  me  at  all  probable  that 
s^-philitic  aortitis,  the  commonest  form  of  cardiac  syphilis,  is  present. 

Pulmonary  stenosis  or  mitral  disease,  which  were  among  the  diag- 
noses suggested  in  the  case,  should  give  a  very  different  x-ray  picture 
from  that  which  is  shown  in  Fig.  161. 

Moreover,  none  of  these  diseases  has  any  right  to  give  a  con- 
tinuous murmur,  lasting  through  the  whole  cardiac  cycle.  I  think  it 
would  be  of  some  interest  if  I  record  some  of  the  opinions  given  in 
the  case. 

Outcome. — The  following  opinions  were  expressed:  Syphilitic 
aortitis,  with  ulceration  into  the  pulmonary  artery.  Dr.  Roger  I.  Lee; 
syphiUtic  aortitis,  with  extension  to  the  aortic  valve.  Dr.  James  H. 
Wright  and  Dr.  Charles  H.  Lawrence;  aortic  stenosis  and  regurgita- 
tion, Dr.  Wm.  H.  Smith;  aortic  and  mitral  regurgitation,  with  steno- 
sis of  the  pulmonary  artery,  Dr.  Frederick  C.  Shattuck;  pulmonary 
stenosis  and  regurgitation,  Dr.  George  C.  Shattuck;  congenital  heart 
disease,  with  patent  ductus  arteriosus.  Dr.  Frederick  T.  Lord  and 


HEMOPTYSIS 


447 


Dr.  F.  W.  Palfrey;  congenital  lesions,  probably  patent  ductus  arte- 
riosus or  septal  defect,  Dr.  Richard  C.  Cabot.  By  May  2d  the 
patient  seemed  perfectly  strong  and  well,  had  no  symptoms  of  any 
kind,  and  was  allowed  to  go  home. 

Case  188 

A  housewife  of  thirty-one  entered  the  hospital  August  31,  19 10. 
Ten  days  ago  the  patient  had  a  miscarriage.  Since  then  she  has 
been  feverish  and  had  one  or  more  chills  each  day.  Four  days  ago 
she  had  pain  in  the  right  side  of  the  chest  and  began  to  raise  bloody 


Fig.  162. — Chest  signs  in  Case  188. 

sputa.  Previous  history  and  family  history  negative,  but  she  has 
had  three  miscarriages,  including  the  one  just  mentioned.  Previous 
to  that  she  had  three  healthy  children. 

Physical  examination  showed  obesity,  pallor,  cyanosis,  twitching 
of  the  hands  and  arms.  The  tongue  was  very  dry  and  cracked,  with 
a  thick,  brown  coat.  Pupils,  glands,  and  reflexes  negative.  Heart 
negative,  save  for  a  systoHc  murmur,  loudest  in  the  third  left  inter- 
space. The  left  lung  was  normal.  The  right  showed  dulness  through 
the  back,  with  increased  voice  sounds.  Breathing  bronchial  near  the 
angle  of  the  scapula  over  an  area  size  of  the  palm,  elsewhere  dimin- 
ished.    In  the  front  there  was  friction  between  the  right  nipple  and 


448 


DIFFERENTIAL  DIAGNOSIS 


the  axilla,  and  the  breathing  beneath  the  right  clavicle  was  dimin- 
ished (Figs.  162,  163).     Abdomen  negative. 

There  was  a  foul  vaginal  discharge.  The  patient  was  actively 
dehrious.  Temperature  as  seen  in  Fig.  164.  The  urine  averaged  35 
ounces  in  twenty-four  hours;  specific  gravity  between  1013  and  1018; 
albumin  present  in  slight  traces  up  to  the  first  of  October,  and  then 
usually  absent.  The  sediment  showed  at  first  granular  casts  with 
cells  adherent;  later  on,  nothing  of  interest.  The  blood  showed  at 
entrance  3,000,000  red  cells.  A  week  later  it  had  fallen  to  2,300,000, 
from  which  point  it  gradually  rose  until,  on  the  27th,  the  cells  num- 


Vo\te  S>nuv\8«)   + 


[Dul-nes?). 

I  Mo-tW   81m.  tr. 


■broTacUift.? 
brEa-tKiv\<j. 


Fig.  163. — Chest  signs  in  Case  i5 


bered  4,000,000.  Hemoglobin  was  40  per  cent,  at  entrance  and 
gradually  rose  to  60  per  cent.  The  white  corpuscles  varied  from 
16,000  to  20,000  during  the  first  week;  after  that  remained  in  the 
neighborhood  of  12,000.  October  12th  the  last  blood  examination 
showed  reds  4,800,000;  whites,  8000;  hemoglobin,  80  per  cent.  The 
smear  in  the  earlier  days  of  her  illness  showed  moderate  achromia, 
considerable  variation  in  size,  and  a  good  deal  of  abnormal  staining. 
On  the  14th  four  normoblasts  and  three  megaloblasts  were  seen  while 
counting  200  white  cells.  All  of  these  abnormalities  disappeared 
before  she  left  the  hospital.  Blood-culture  August  31st  was  nega- 
tive. 


HEMOPTYSIS 


449 


The  sputum  was  very  profuse,  purulent,  foul,  and  contained  a 
variety  of  organisms.  No  tubercle  bacilli  or  other  predominating 
organisms  could  be  discovered.  The  vaginal  discharge  soon  ceased 
to  be  foul  and  the  pelvis  showed  nothing  markedly  abnormal.     Each 


morning  she  was  comfortable  and  in  good  condition.  Toward  night 
she  usually  had  a  chill,  became  restless  and  dehrious,  with  a  weak 
pulse,  high  temperature,  and  respiration.  The  evidences  of  pulmonary 
solidification  were  quite  clear  during  the  first  week,  but  after  the  6th 

Vol.  11—29 


45° 


DIFFERENTIAL  DIAGNOSIS 


of  September  the  lungs  were  much  clearer,  though  the  chills  and 
sweats  contmued. 

The  uterine  discharge  had  almost  ceased  by  September  6th. 
September  8th  the  heart's  apex  extended  to  the  anterior  axillary  line 
and  there  was  a  soft  systolic  murmur  there.  On  the  2 2d  of  September 
the  signs  seemed  obviously  those  of  pulmonary  abscess  or  gangrene, 
though  no  localization  could  be  made.  On  the  9th  of  October  in  the 
right  axilla  there  was  tympanitic  resonance,  amphoric  breathing,  and 
cracked-pot  sound.  Nevertheless,  the  patient  seemed  much  better. 
The  sputum  was  still  profuse  and  somewhat  bloody.  October  nth 
she  was  sitting  up  in  a  chair  daily,  and  from  the  13th  of  October  a 
chart  was  kept  showing  the  amount  of  sputum  daily  (Fig.  165) .  Cough 
was  easily  brought  out  on  change  of  position.  The  fingers  were  sHghtly 
clubbed. 


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Fig.  165. — Shows  daily  variations  in  the  number  of  ounces  of  sputum. 

October  21st  ic-ray  showed  diffuse  shadow  throughout  the  right 
lung,  but  no  recognizable  cavity. 

Discussion. — Of  special  importance,  it  seems  to  me,  is  the  fact 
that  this  patient's  symptoms  came,  immediately  after  a  miscarriage. 
Pulmonary  symptoms  at  such  a  time  should  always  suggest  thrombosis 
of  the  periuterine  veins,  with  resulting  pulmonary  embolism,  bland 
or  septic.  The  fact  that  chills  accompanied  the  hemoptysis  and 
chest  pains  leads  us  to  imagine  that  the  embolism  is  of  the  septic 
type. 

In  the  present  case  reasoning  of  this  t3^e  seems  to  help  us  rather 
more  than  an  attempt  to  make  a  diagnosis  from  the  physical  signs. 
The  signs  in  the  lungs  will  fit  almost  any  pulmonary  disease — phthisis, 
pneumonia,  abscess,  pleurisy,  etc.  Much  more  often  than  we  are  apt 
to  admit,  this  is  true  of  pulmonary  disease,  and  the  correctness  of  our 
diagnosis  depends  more  upon  our  general  pathologic  knowledge,  our 
study  of  the  sputa,  and  the  history  than  upon  what  we  learn  by 
auscultation  or  percussion. 


HEMOPTYSIS  45 1 

The  anemia,  the  fever,  and  leukocytosis  are  consistent  with  any 
one  of  the  pulmonary  diagnoses  just  listed.  Of  decisive  importance 
is  the  condition  of  the  sputum,  which  is  characteristic  of  abscess  and 
distinctly  different  from  that  of  bronchiectasis,  phthisis,  pneumonia, 
or  empyema.  Of  special  interest  is  the  sputum  chart  presented  here- 
with, and  showing  how  the  enormous  amount  of  sputum  (almost 
I  quart  in  twenty-four  hours  at  the  start)  gradually  fell  to  zero. 

In  all  probability,  then,  we  are  dealing  with  a  septic  embolus  of 
the  lung,  thrown  off  from  the  periuterine  fiexus  or  veins  which  had 
become  clogged  and  infarcted  as  a  result  of  the  septic  miscarriage. 
Hemoptysis  is  not  the  rule  in  such  a  case,  but  is  not  at  all  rare. 

Outcome. — From  October  21st  the  amount  of  sputum  rapidly 
diminished,  the  temperature  ranged  lower,  and  finally  disappeared, 
while  the  patient  gained  steadily  in  weight  and  strength.  Oil  of 
eucal3^tol,  10  minims,  three  times  a  day,  began  September  17th. 
The  patient  weighed  170  pounds  when  she  left  the  hospital  in  excel- 
lent condition  on  the  30th  of  October. 

Case  189 

A  housewife  of  sixty-two,  born  in  Russia,  entered  the  hospital 
August  19,  1910.  The  patient  states  that  eighteen  years  ago  she 
brought  up  about  ^  cupful  of  blood,  whether  by  coughing  or  otherwise 
she  cannot  state;  otherwise  she  has  been  well.  She  has  had  twelve 
children  and  no  miscarriages.  Menopause  occurred  twenty  years 
ago. 

Two  days  ago  she  coughed  up  about  a  cupful  of  blood,  and  since 
then  has  had  a  sHght  cough  and  raised  a  small  amount  of  blood. 
Family  history  is  negative;  habits  good. 

Physical  examination  shows  poor  nutrition;  cataract  in  the  right 
eye.  Left  pupil  non-circular  and  eccentric,  but  reacting  normally. 
Glands  and  reflexes  normal.  Lungs  negative.  The  heart's  apex 
found  in  the  sixth  space,  14  cm.  from  midsternum.  Aortic  second 
sound  metallic  and  ringing.  Blood-pressure,  165  mm.  Hg.,  systolic. 
No  murmurs.  Artery  walls  tortuous  and  thickened.  Abdomen  very 
much  relaxed.  Right  kidney  palpable.  Liver  edge  felt  three-fingers' 
breadth  below  the  ribs. 

A  lar5nigologist  could  find  no  bleeding  points  in  the  nose,  larynx, 
or  trachea.  On  the  day  after  her  entrance  she  raised  6  or  7  ounces  of 
bright  alkaline  blood;  4  mg.  of  old  tuberculin  was  injected  under  the 
skin,  and  was  followed  by  a  rise  in  temperature  to  101°  F.  without 
constitutional  symptoms.     The  sputum  was  examined  three  times  for 


452  DIFFERENTIAL  DIAGNOSIS 

tubercle  bacilli  with  negative  results.  On  the  3d  of  November,  as  she 
felt  perfectly  well,  she  was  allowed  to  go  home. 

Discussion. — That  the  patient's  first  hemoptysis,  eighteen  years 
ago,  did  not  seriously  impair  her  health,  seems  to  be  the  fact.  Ap- 
parently she  underwent  no  treatment  after  it  and  has  had  no  symp- 
toms. This  is  all  the  more  interesting  and  significant  because,  in 
the  minds  of  many  physicians,  this  would  constitute  proof  that  it  was 
not  of  tuberculous  origin.  Yet  now,  after  the  lapse  of  eighteen  years, 
we  have  a  repetition  of  hemoptysis,  which  was  this  time  of  consider- 
able amount  and  occurred  under  observation  in  the  hospital,  so  that 
there  can  be  no  possible  doubt  as  to  the  fact,  yet  still  no  signs  appear 
in  the  lungs. 

The  heart  is  not  normal,  but  there  is  nothing  about  it,  nor  about 
any  part  of  the  body,  to  suggest  a  failing  cardiac  compensation  or  any 
such  pulmonary  suggestion  as  could  produce  hemorrhage  by  infec- 
tion. Undoubtedly  she  has  arteriosclerosis  and  a  low,  sagging  liver, 
the  latter  accounted  for  probably  by  the  abdominal  relaxation  fol- 
lowing her  twelve  pregnancies. 

The  tubercuhn  reaction  is  proof  of  tuberculosis,  obsolete  or  active, 
past  or  present,  but  has  no  necessary  bearing  upon  her  present  symp- 
toms. If  she  were  younger  we  should  have  no  doubt  of  the  diagnosis 
of  tuberculosis.  As  it  is  I  cannot  feel  sure,  and  must  leave  the  case 
in  doubt.  Tuberculosis,  however,  seems  to  me  the  most  probable 
theory. 

Outcome. — She  was  seen  again  in  December,  1910,  and  December 
30,  191 1,  and  had  had  no  recurrence  of  symptoms.  February,  1913, 
she  reported,  looking  and  feeling  perfectly  well.  Physical  examination 
of  the  lungs  negative;  of  the  heart  unchanged. 

Case  190 

A  woman  of  twenty-four  entered  the  hospital  November  i,  1910. 
The  patient  has  a  negative  family  history  and  has  been  well  until 
within  the  past  year,  though  she  has  had  a  number  of  attacks  of 
tonsilUtis.  For  a  year  she  has  felt  poorly  and  been  below  her  normal 
weight.  Varicose  veins  were  excised  by  Dr.  Bottomley  at  the  Carney 
Hospital  a  few  months  ago. 

For  a  month  she  has  complained  of  pain  in  her  right  shoulder, 
and  for  a  few  weeks  she  has  had  pain  and  swelling  in  the  region  of 
the  right  tonsil.  After  a  chest  examination,  to  see  if  there  were  any 
contra-indications  for  operation  upon  the  tonsil,  the  tonsils  were  re- 
moved by  Dr.  Mosher,  six  weeks  ago.     For  five  days  after  operation 


HEMOPTYSIS 


453 


she  did  well  and  had  no  temperature;  then  she  complained  of  acute 
pain  in  the  left  lumbar  region,  but  examination  disclosed  nothing. 
After  going  home  from  the  hospital  where  this  operation  was  done 
she  continued  to  cough,  the  expired  air  being  very  foul.  For  a  month 
she  has  been  feverish,  the  temperature  reaching  ioo°  F.  in  the  morning, 
103°  F.  in  the  evening.  She  has  remained  in  bed.  At  the  beginning 
of  this  period  a  patch  of  bronchopneumonia,  the  size  of  a  dollar,  was 
found  half-way  between  the  left  nipple  and  the  clavicle.  There  were 
also  a  few  fine  rales  in  the  left  back.     Later  these  disappeared.     Five 


0^    SUtCU^siOTX  ^ 


Increase  6  resoy^ante 
almost    tyvMJjaviy 
^      +  voice. 

hYnor\)\\\'t   br. 


Fig.  166. — Chest  signs  in  Case  190. 

days  ago  the  sputum  was  blood  stained.  Three  days  ago  a  slight  dulness 
was  found  in  the  right  back,  accompanied  by  fine,  moist  rales.  Last 
night  signs  of  cavity  were  discovered  in  the  left  chest.  The  amount 
of  sputum  has  been  i  or  2  ounces  a  day. 

On  physical  examination  the  patient  was  emaciated  and  constantly 
raised  very  foul  sputum.  The  lymph-nodes  in  the  left  side  of  the  neck 
were  enlarged.  The  pupils  and  reflexes  were  normal.  In  the  left  front 
was  an  area  of  tympanitic  resonance,  as  depicted  in  Figs.  166  and  167. 
Over  this  area  was  amphoric  breathing,  cracked-pot  sound,  coin  sound, 
and  increased  voice,  also  a  few  fine  rales  at  the  lower  margin  of  the 


454 


DIFFERENTIAL  DIAGNOSIS 


Fig.  167. — Chest  signs  in  Case  190. 

area.     These  signs  extended  into  the  left  axilla,  but  were  less  marked 
in  the  back.     The  heart  and  abdomen  negative.     The  urine  showed 


?5 


a  trace  of  albumin,  0.5  per  cent,  of  sugar,  specific 

^^7- gravity  1023;  twenty-four-hour  amount  not  accu- 
rately recorded.  Temperature  as  in  Fig.  168. 
Leukocytes  20,000,  with  a  polynuclear  leukocytosis. 
Hemoglobin,  70  per  cent.  On  the  afternoon  of  en- 
trance, after  a  prolonged  surgical  examination,  the 
patient  raised  nearly  8  ounces  of  pure  blood. 

Discussion.— The  patient  has  had  two  surgical 
operations,  either  of  which  might  have  resulted  in  a 
lung  complication.  Lung  abscesses  after  tonsillar 
operations,  owing  to  the  inhalation  of  septic  ma- 
terial during  the  operation,  are  very  rare,  but 
should  be  reckoned  among  the  possible  risks  in- 
volved in  even  so  slight  an  operation  as  tonsil- 
lectomy. 

On  the  whole,  the  operation  of  excising  varicose 
veins  is  one  that  might  be  followed  by  thrombosis 
of  the  veins  higher  up,  and,  finally,  by  pulmonary 
embolism  and  resulting  abscesses  or  infection.  The 
physical  signs  as  shown  in  such  cases  are  not  distinctive,  but  the  odor 
of  the  breath  leaves  no  doubt  that  we  are  deahng  with  an  abscess. 


^ 


Fig.  168. — Chart  in 
Case  190. 


HEMOPTYSIS  455 

Can  this  abscess  be  tuberculous  in  origin?  The  character  of  the 
sputum  is  wholly  against  it.  A  patient  whose  tuberculosis  was  so 
extensive  as  to  result  in  so  large  a  bulk  of  sputum  would  almost  cer- 
tainly have  demonstrable  signs  in  the  other  lung. 

Bronchiectasis,  which  may  be  associated  with  a  very  foul  sputum, 
rarely  develops  in  so  short  a  time  and  is  almost  invariably  bilateral. 

Outcome. — At  four  the  next  morning  she  had  an  attack  of  cyanosis, 
with  shallow,  difhcult  breathing,  and  died.  Autopsy  No.  2712  showed 
abscess  and  gangrene  of  the  upper  lobe  of  the  left  lung  with  excessive 
hemorrhage;  fetid  bronchitis;  obsolete  tuberculosis  of  a  bronchial 
lymphatic  gland. 

Case  191 

November  i,  1902,  an  Irish  ward  maid  of  the  hospital,  nineteen 
years  old,  was  taken  into  the  ward.  She  had  diphtheria  in  the  pre- 
vious January  and  was  ill  six  weeks.  Otherwise  she  has  always  been 
well.  Her  family  history  is  negative.  Her  habits  are  good.  Her 
menstruation  is  normal,  except  for  considerable  pain.  Yesterday  she 
noticed  sore  throat,  chills,  headache,  backache,  coryza,  watering  of  the 
eyes.     Last  evening  she  vomited  four  times. 

Physical  examination  showed  large  reddened  tonsils,  with  whitish 
exudate  and  enlarged  glands  below  the  angle  of  the  right  jaw.  Cul- 
tures from  the  throat  were  negative.  After  a  week  in  the  wards  the 
patient  seemed  to  be  practically  all  right  and  went  back  to  work. 
March  16,  1903,  she  had  a  similar  attack  and  was  in  the  ward  five 
days,  but  recovered  promptly.  January  6,  1905,  she  entered  for  the 
third  time,  stating  that  five  years  ago  and  three  years  ago  she  had  had 
attacks  like  the  present,  when  she  vomited  considerable  blood,  al- 
though nothing  relating  to  this  is  contained  in  either  of  the  pre\^ous 
hospital  records.  The  patient  also  stated  at  this  time  that  one  sister 
had  died  of  consumption. 

Thirteen  days  ago  she  began  to  have  sharp  epigastric  pain  radiat- 
ing to  the  back.  It  was  constant,  increased  by  pressure,  not  increased 
or  reheved  by  food.  The  pain  lasted  two  days,  then  ceased  for  two 
days,  began  again  and  lasted  twelve  hours,  then  left  her  until  this 
morning.  Twelve  days  ago  and  eleven  days  ago  she  either  vomited 
or  coughed  up  3  or  4  ounces  of  dark  blood,  none  since.  She  states  that 
for  two  years  she  has  had  pain  during  micturition. 

Physical  examination  showed  good  nutrition,  normal  throat,  nega- 
tive chest  and  abdomen.  The  patient  remained  three  months  in  the 
ward,  and  during  most  of  that  time  had  no  fever.     On  a  few^  occasions, 


456  DIFFERENTIAL   DIAGNOSIS 

to  be  mentioned  subsequently,  there  was  a  short  period  of  pyrexia. 
The  blood  at  entrance  showed  15,400  white  cells;  hemoglobin,  90  per 
cent.  The  urine  was  negative  save  for  the  slightest  possible  trace  of 
albumin.  The  patient  was  kept  on  nutrient  enemata  for  six  days, 
and  after  that  did  weW  on  feeding  by  mouth.  From  time  to  time  she 
had  some  abdominal  distress  or  vomiting,  the  vomitus  once  con- 
taining several  streaks  of  blood. 

On  the  8th  of  February  she  vomited  about  2  ounces  of  bright  blood. 
March  3d  this  happened  again.  In  the  meantime  she  was  free  from 
pain  and  eating  well.  On  the  7th  blood  was  found  in  the  basin  by 
her  side.  It  seemed  to  be  mixed  with  mucus  or  sputum.  Examina- 
tion of  the  lungs  showed  questionable  dulness  and  increase  of  voice 
sounds  at  the  left  apex.  The  sputum  was  repeatedly  examined  for 
tubercle  bacilli  without  results.  Guaiac  tests  of  the  stools  were 
negative.  After  10  mg.  of  tuberculin  the  temperature  rose  to  102.5°  F. 
This  was  the  only  period  of  considerable  pyrexia  during  the  whole 
three  months  of  her  stay. 

On  the  2  2d  of  March  there  was  again  a  question  of  the  source  of 
blood  found  in  the  basin  beside  her.  The  blood  was  mixed  with 
mucus  and  had  a  faintly  acid  reaction.  It  became  clear  at  this  time 
that  she  was  very  untruthful  as  well  as  impudent.  She  refused  to 
leave  the  ward  when  it  came  time  for  her  to  go,  but  was  discharged, 
nevertheless,  March  30th.  Gastric  ulcer  and  pulmonary  tuberculosis 
were  the  diagnoses  considered,  but  no  definite  evidences  of  either  dis- 
ease was  obtained. 

She  was  again  in  the  ward  in  June,  1905,  in  the  meantime  having 
been  at  Rutland  Sanitarium  for  tuberculosis.  While  there  she  had 
much  epigastric  pain,  increased  by  food,  never  relieved  by  it,  and 
vomited  once  a  day  sometimes  and  sometimes  less  frequently.  She 
says  she  has  vomited  no  blood.  She  has  gained  nearly  14  pounds,  and 
has  not  coughed  at  all,  though  she  has  raised  considerable  sputa,  once 
with  a  small  lump  of  blood. 

Physical  examination  shows  that  the  gums  are  spongy  and  bleed- 
ing, the  posterior  pharyngeal  wall  covered  with  mucus.  A  systolic 
murmur,  loudest  at  the  apex,  was  heard  also  in  the  axilla  and  all  over 
the  precordia ;  otherwise  the  chest  was  negative,  likewise  the  abdomen. 
Blood  and  urine  normal.  The  capacity  of  the  stomach  was  2  pints, 
10  ounces;  no  residue  before  breakfast;  after  a  test-meal,  free  HCl  0.087, 
total  acidity,  0.277;  no  blood.  Her  chief  complaint  was  of  pain  about 
the  bladder  during  and  after  micturition  and  a  pain  in  the  lower  part 
of  the  back,  considered  by  our  orthopedic  consultant,  Dr.  Robert  B, 


HEMOPTYSIS 


457 


Osgood,  to  be  of  attitudinal  origin.  The  course  of  the  patient's 
temperature  is  seen  in  Fig.  169.  On  the  21st  she  was  impudent  and 
disobedient,  and  told  that  she  would  be  discharged  the  next  day. 
The  next  day  she  developed  earache,  abdominal  cramps,  pain  in  the 
back,  and  many  other  symptoms.  Examination  of  the  ears  was  nega- 
tive. She  was  kept  in  the  ward,  and  then  seemed  perfectly  contented. 
No  cause  for  the  fever  could  be  found. 

On  the  2d  of  July  she  was  allowed  to  get  up  and  showed  no  ill 
effects.  On  the  3d  of  July  it  was  found  that  the  thermometer  regis- 
tered 104°  F.  The  patient's  pulse  was  low,  skin  cool,  and  there  was 
no  other  evidence  of  fever.     The  patient  was  given  another  thermom- 


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Fig.  169. — Course  of  temperature  (as  recorded)  in  Case  191. 


eter  and  secretly  watched.  She  was  then  seen  to  shake  the  instru- 
ment, point  upward,  so  as  to  make  it  register  high.  The  nurse  then 
took  the  temperature  by  rectum  and  found  it  to  register  98^  F. 
The  next  day  she  refused  to  have  her  temperature  taken.  During 
this  stay  in  the  ward  she  frequently  spat  up  i  or  2  ounces  of  foul- 
smelling  bloody  fluid  which  evidently  came  from  her  gums. 

She  was  discharged  July  4th  and  re-entered  September  2  2d,  stat- 
ing that  she  had  felt  well  and  done  her  work  regularly  since  she  was 
last  in  the  ward.  She  had  vomited  five  or  six  times,  but  never  anything 
abnormal  until  this  morning,  when,  at  three  o'clock,  after  a  restless 
night,  she  vomited  ^  cupful  of  bright  blood.     She  has  a  slight  cough, 


458  DIFFERENTIAL  DIAGNOSIS 

mostly  at  night.  Physical  examination  showed  nothing  abnormal. 
Pelvic  examination  was  negative. 

She  was  discharged  September  25th,  and  re-entered  December  23, 
1905,  having  been  well  in  the  meantime.  Yesterday  at  9  a.  m.  she 
vomited  i  pint  of  dark-brown  fluid  which  she  thought  was  old  blood, 
and  immediately  after  this  a  mouthful  of  bright  blood.  Twice  since 
then  she  has  raised  blood.  Two  days  ago  she  had  a  very  dark-colored 
stool,  otherwise  she  has  noticed  nothing  abnormal  about  the  stools. 
This  time  the  patient  stayed  five  weeks  in  the  wards.  As  on  pre- 
vious occasions,  blood  was  found  in  her  spit-cup,  but  the  source  of  it 
was  not  clear.  Bleeding  points  were  found  on  the  gums.  After  the 
patient  was  told  that  the  bleeding  came  from  the  gums,  she  ceased  to 
spit  blood  until  January  6th,  when,  after  violent  retching,  she  brought 
up  2  or  3  oimces  of  a  mixture  of  food  and  bright  blood.  On  the  23d 
she  seemed  perfectly  well,  and  was  discharged  from  the  ward.  At 
the  foot  of  the  ward  stairs  she  made  a  scene — screamed,  struck  at- 
tendants, and  finally  fell  in  a  limp  heap.  She  was  brought  back  to  the 
ward  and  was  very  difiicult  to  manage,  insulted  the  nurses,  ran  her 
finger  into  her  throat,  and  tried  to  make  herself  vomit,  threatening 
to  take  corrosive  sublimate.  Her  condition  was  explained  to  her 
sister,  and  she  was  discharged  on  the  27th. 

In  February,  1906,  she  got  into  the  Carney  Hospital,  then  under  the 
management  of  a  very  enthusiastic  stomach  surgeon,  and  was  oper- 
ated upon  for  gastric  ulcer  (exploratory  incision;  nothing  foimd). 
After  that  she  had  no  stomach  symptoms  until  September,  19 10, 
but  in  June,  1906,  she  still  complained  of  pain,  and  her  appendix  was 
also  removed  at  the  Carney  Hospital.  At  that  place  she  told  the 
house  officer  that  her  mother  died  of  phthisis. 

In  December,  1906,  she  was  in  the  Boston  City  Hospital,  with  a 
diagnosis  of  intraperitoneal  adhesions,  and,  after  being  treated  medi- 
cally, was  transferred  to  the  surgical  ward  with  a  diagnosis  of  cystic 
ovary,  which  was  operated  upon  in  the  usual  manner,  February  14, 
1907. 

Re-entered  Massachusetts  General  Hospital  February  9,  191 1. 
Since  operation  at  City  Hospital  she  has  been  much  less  well,  has  had 
much  sharp  pain  in  the  lower  abdomen  and  occasional  sharp  pains 
in  the  rectum;  also  frequent  and  painful  urination.  Physical  examina- 
tion showed  nothing  new  except  three  surgical  scars  on  the  abdomen. 
February  9th  she  passed  about  80  c.c.  of  bright  red  blood  into  the  bed. 
Twice  after  that  bright  blood  was  found  in  her  bed-pan  or  in  her  bed. 
Proctoscope  examination  by  Dr.  Brewster  was  entirely  negative.     The 


HEMOPTYSIS 


459 


patient  was  evidently  rejoiced  by  the  prospect  of  some  operation, 
deeply  enjoyed  the  preparations  for  it  and  the  trip  to  the  amphi- 
theater. From  March  ist  to  March  6th  she  ejected  a  good  deal  of 
blood  from  the  mouth  and  some  from  the  rectum.  On  the  z^lh  she 
was  transferred   to   a  private  ward   and  constantly   watched.     There 


was  then  no  blood  passed  from  any  source  until  the  29th,  when  she  was 
caught  rubbing  her  gums,  and  raised  a  mouthful  of  watery  blood.  On 
the  5th  of  April  she  was  discharged  as  a  malingerer.  Later,  she  wrote 
a  long  rambh'ng  letter  and  something  apparently  intended  for  a  poem. 
After  her  transfer  to  Ward  C,  and  careful  watching,  the  irregular  fever 
which  had  been  present  before  (Fig.  170)  disappeared,     February  9th 


460  DIFFERENTIAL   DIAGNOSIS 

the  red  cells  were  3,300,000;  hemoglobin,  70  per  cent.,  slight  achromia, 
moderate  variations  in  size  and  shape.  March  nth,  191 1,  red  cells, 
4,100,000;  hemoglobin,  80  per  cent. 

Discussion. — This  is  one  of  the  most  interesting  and  remarkable 
cases  that  has  ever  come  to  my  notice.  There  is  no  possible  doubt 
that  she  was  malingering;  that  she  deceived  us  into  the  behef  that  she 
had  fever  and  hemoptysis  when  there  was  no  such  thing.  On  the  other 
hand,  there  is  no  doubt  that  her  gums  were  spongy  and  bleeding  and 
that  she  did  not  produce  this  condition  herself.  Granted  that  she 
did  not  have  any  of  the  diseases  which  were  most  seriously  consid- 
ered in  her  case,  especially  phthisis  and  peptic  ulcer;  granted  that  the 
stay  at  the  hospital  for  tuberculosis  was  a  farce,  we  still  have  to  ex- 
plain her  hemorrhagic  tendency. 

Outcome. — Further  letters  from  the  patient  show  that  January 
I,  1 9 14,  she  was  still  in  a  hospital,  making  a  record  of  twelve  years, 
during  which,  to  our  knowledge,  she  has  been  going  from  hospital  to 
hospital.  During  that  time  she  has  been  operated  upon  seven  times 
and  has  been  in  six  different  hospitals — a  most  noteworthy  example 
of  the  harm  that  can  be  done  because  surgeons  do  not  study  their 
cases  and  because  hospitals  do  not  co-operate  with  one  another. 

In  the  spring  of  191 2  the  patient's  hemoglobin  got  down  as  low  as 
20  per  cent.  It  is  clear  that  she  must  have  lost  a  good  deal  of  blood. 
The  cause  of  this,  and  what,  if  any,  participation  her  own  morbid  ac- 
tions had  in  it,  I  cannot  say. 

Case  192 

A  weaver  of  thirty-three,  a  Finlander,  entered  the  hospital  June 
26,  191 1.  The  patient  has  an  excellent  family  history  and  was  never 
sick  until  three  years  ago,  when  he  had  an  attack  like  the  present. 
He  takes  about  i  pint  of  whisky  each  Saturday  and  occasionally 
earlier  in  the  week. 

Three  years  ago  and  one  year  ago  he  had  an  attack  like  the  pres- 
ent. Three  times  during  the  past  year  these  attacks  have  been 
repeated.  On  the  loth  of  June  he  raised  a  few  ounces  of  bright  blood. 
This  evening  he  raised  about  10  ounces  in  the  same  way.  He  has  no 
cough,  no  pain,  and  feels  perfectly  well  in  other  respects.  Seven  years 
ago  he  weighed  156  pounds;  now,  145  pounds.  Laryngologic  ex- 
amination in  the  Out-patient  Department  showed  the  vessels  at  the 
base  of  the  tongue  rather  large,  the  larynx  somewhat  injected,  a  little 
blood  on  the  trachea  below  the  vocal  cords.  The  sputum  was  ex- 
amined five  times  for  tubercle  bacilU  without  results. 


HEMOPTYSIS 


461 


The  patient  was  powerfully  built  and  looked  well.  At  entrance 
the  lungs  and  the  rest  of  the  physical  examination  were  entirely 
negative.  He  continued  to  raise  purulent  sputum  mixed  with  dark 
blood.  During  the  first  week  of  his  stay  he  had  no  temperature 
above  99.2°  F.  The  second  week  it  touched  100°  F.  several  times,  and 
never  fell  below  99°  F.  His  systolic  blood-pressure  was  115.  Blood 
and  urine  normal.  X-ray  showed  mottling  at  the  roots  of  both 
lungs,  most  marked  on  the  right;  the  right  apex  was  also  mottled 
(Fig.  171).  Some  of  the  blood  raised  July  ist  was  injected  into  a 
guinea-pig.  August  5th  the  pig  was  killed.  Autopsy  showed  tuber- 
culosis. 

Discussion. — Here  we  have  four  attacks  of  hemoptysis  in  three 
years.     The  laryngologic  examination  is  of  great  value,  demonstrat- 


9~^^~--~ ^\_  .iC.cc*>.?  skoot^w* 


lkafl.h 


Fig.  171. — Sketch  of  a;-ray  plate  in  Case  192.     The  shadows  at  the  lung  roots  seemed 
rather  more  marked  than  in  the  average  case. 


ing,  as  it  does,  that  the  blood  comes  from  below  the  vocal  cords  and 
in  all  probability  from  the  lung.  Yet  against  this  we  have  the  five 
negative  sputum  examinations  and  the  absence  of  any  physical  signs 
pointing  to  pulmonary  abscess,  bronchiectasis,  or  any  other  local 
lung  lesions  ordinarily  associated  with  hemopt3'sis. 

The  point  of  special  interest  in  the  case  is  the  fact  that  through 
animal  inoculation  we  were  able  to  prove  the  presence  of  tubercu- 
losis, when  by  other  methods  it  would  have  been  impossible.  The 
search  for  tubercle  bacilli  in  bloody  sputa  is  particularly  unsatisfac- 
tory, and  yet  such  sputum  can  well  be  used  for  animal  inoculation. 

Outcome. — The  patient  left  the  hospital  on  the  8th,  and  returned 
to  Finland,  where  he  cannot  be  traced. 


462  DIFFERENTIAL  DIAGNOSIS 

Case  193 

A  German  gardener  of  thirty  entered  the  hospital  January  10, 
1912.  The  patient  has  ahvays  been  well  and  strong  until  a  year  ago, 
when  the  right  eye  suddenly  became  swollen,  painful,  and  inflamed. 
An  ulcer  followed,  and  he  was  ill  a  month  with  it.  Seven  months  ago, 
without  any  warning  whatever,  he  spat  up  a  mouthful  of  bright  blood 
shortly  after  eating.  There  was  tickling  in  the  throat,  he  coughed 
slightly,  and  up  came  the  blood.  The  attending  physician  could  find 
no  cause  for  the  trouble,  and  he  seemed  all  right  again  the  next  day. 
Five  months  ago  the  same  thing  happened  again.  Three  and  a  half 
months  ago  he  had  a  third  attack.  Ten  days  ago  he  was  watching  a 
gang  of  men  blasting,  ran  to  escape  a  blast,  suddenly  felt  nauseated, 
and  spat  up  two  or  three  mouthfuls  of  dark  blood.  Since  then  he  has 
raised  at  least  a  mouthful  of  blood  daily,  and  at  least  twice  has  raised 
eight  to  twelve  mouthfuls,  the  last  time  two  nights  ago. 

He  feels  perfectly  well,  has  worked  steadily,  and  never  coughs 
except  when  raising  blood.  He  has  no  fever  or  sweats  and  has  never 
vomited.  Appetite,  bowels,  and  sleep  are  normal.  No  dyspnea  or 
edema.     No  headache  or  change  in  eyesight.     No  loss  of  weight. 

On  examination  by  a  laryngologist  in  the  Out-patient  Department 
free  blood  was  seen  on  the  tracheal  wall  below  the  larynx.  In  the 
ward  he  proved  to  be  well  nourished;  the  right  eye  showed  anterior 
staphyloma,  the  left  normal.  Glands  and  reflexes  normal.  Chest 
and  abdomen  negative.  Wassermann  reaction  negative.  Examina- 
tion of  the  eye  by  Dr.  Quackenbos  showed  that  the  iris  was  tied  to 
the  scar  in  the  cornea  on  the  lower  and  outer  side.  The  ocular  tension 
was  increased.  The  left  eye  also  showed  scars  on  the  cornea.  Five 
examinations  of  sputa  were  negative.  Blood  and  urine  negative. 
Blood-pressure,  125  mm.  Hg.,  systolic;  a;-ray  showed  peribronchial 
thickening  to  the  right  of  the  sternum,  calcified  spots  at  both  apices, 
a  prominent  aortic  arch.  The  patient  was  given  i  mg.  of  old  tuber- 
culin subcutaneously,  had  no  reaction,  but  after  5  and  7  mg.  the 
temperature  rose  to  101°  F.  No  physical  signs  developed  in  the  lungs 
after  these  injections  and  there  was  no  general  malaise.  There  was  a 
slight  local  reaction  at  the  site  of  injection,  and  the  von  Pirquet 
reaction,  which  had  been  moderately  positive  before  the  subcuta- 
neous injections,  was  much  more  markedly  so  afterward.  No  further 
facts  could  be  brought  out,  and,  accordingly,  the  patient  went  home 
on  the  2 1  St. 

Discussion. — I  have  no  means  of  knowing  what  ailed  the  patient's 


HEMOPTYSIS  463 

eye  and  no  good  reason  for  connecting  it  with  the  present  seven 
months'  ilhiess.  Regarding  the  hemoptysis,  I  want  to  call  attention 
to  the  fact  that -the  blood  came  up  in  the  characteristically  stealthy 
way  in  which  blood  appears  in  pulmonary  tuberculosis.  Now  and 
then  blood  comes  with  hard  coughing,  but  in  the  majority  of  cases  the 
patient  is  astounded  to  find  blood  in  his  mouth  and  is  by  no  means 
sure  where  it  comes  from.  Often  he  is  unaware  of  having  done  any- 
thing whatever  to  cause  it;  is  quite  sure  he  has  not  coughed. 

This  type  of  hemoptysis,  as  I  say,  is  particularly  characteristic 
of  tuberculosis. 

The  laryngologic  examination,  proving  that  the  blood  comes  from 
below  the  larynx,  adds  a  valuable  piece  of  evidence  pointing  in  the 
same  direction.  The  five  negative  examinations  of  the  sputa  do  not 
in  any  way  exclude  tuberculosis.  On  the  other  hand,  the  x-ray  find- 
ings and  the  tubercuHn  reaction  do  not  prove  anything.  They  might 
both  of  them  correspond  to  a  wholly  obsolete  or  healed  process  of  no 
present  significance.  This  is  just  the  sort  of  case  in  which  animal 
inoculation  with  the  blood  or  sputum  raised  would  be  of  the  greatest 
importance.  Nevertheless,  despite  the  absence  of  any  such  inocula- 
tion, the  subsequent  history  of  many  similar  cases  convinces  me  that 
this  patient  is,  in  all  probability,  tuberculous. 

Case  194 

An  engineer  of  forty-six  entered  the  hospital  January  22,  191 2. 
The  patient's  father  died  of  heart  trouble;  his  mother,  of  dropsy.  He 
had  rheumatism  when  a  boy  in  two  attacks,  each  lasting  all  winter 
and  keeping  him  on  crutches.  He  has  slept  with  at  least  two  pillows 
all  his  Hfe.  For  the  past  four  years  he  has  passed  urine  five  times  each 
night.  A  year  ago  he  had  "pneumonia"  in  both  lungs  and  was  sick 
seven  weeks.     His  habits  are  excellent. 

Since  the  pneumonia  he  has  been  short  of  breath  on  exertion, 
but  otherwise  has  done  his  work,  as  a  stationary  engine  fireman, 
without  any  trouble.  Seven  weeks  ago,  after  a  physical  strain,  he 
began  spitting  blood,  and  in  the  course  of  a  night  raised  almost  a  quart. 
After  that  his  wind  became  so  short  that  he  could  not  work  and  when 
he  lay  down  he  choked.  Soon  after  the  hemorrhage  his  legs  began  to 
swell.  He  has  not  been  in  bed,  has  a  good  appetite,  and  no  head- 
ache or  dizziness. 

Physical  examination  shows  fair  nutrition,  marked  pallor,  normal 
pupils,  glands,  and  reflexes.  The  heart's  apex  extends  3  cm.  outside 
the  nipple  line.     The  aortic  and  pulmonic  second  sounds  are  both 


464  DIFFERENTIAL  DIAGNOSIS 

sharp,  the  latter  reduplicated.  There  is  no  fever;  there  are  rales  at 
the  bases  of  both  lungs,  and  at  the  right  apex  dulness,  bronchovesicular 
breathing,  and  crackles,  extending  down  to  midscapula  and  to  the 
third  rib  in  front.  The  arteries  were  very  rough  and  tortuous,  the 
abdomen  negative,  save  for  tenderness  and  resistance  under  the  right 
ribs.  Wassermann  reaction  negative.  Urine,  70  ounces  in  twenty- 
four  hours;  specific  gravity,  1008;  slight  trace  of  albumin,  no  casts. 
Red  cells,  3,500,000;  white  cells,  15,000;  hemoglobin,  60  per  cent. 
Stained  smear  shows  deformities  in  size  and  shape,  polynuclear 
leukocytosis,  with  82  per  cent,  of  polynuclear  cells.  Blood-pressure 
at  entrance,  220  mm.  Hg.,  systolic;  130  mm.  Hg.,  diastolic.  On  the 
27th  it  was  290  mm.  Hg.,  systolic;  150  mm.  Hg.,  diastoHc.  No 
temperature  in  a  week's  observation.  On  the  24th  the  evidences  of 
soHdification  had  disappeared,  though  there  were  still  numerous  fine 
crackles  over  the  right  apex,  front  and  back.  The  edema  disap- 
peared soon  after  entrance  and  the  lungs  slowly  cleared,  but  the  patient 
did  not  gain.  He  slept  a  good  deal  of  the  time  and  seemed  on  the 
edge  of  delirium.  A  hot-air  bath  made  him  restless  and  excited.  He 
died  on  the  30th. 

Discussion. — The  patient's  history  of  rheumatism  and  partial 
orthopnea  at  night,  together  with  the  supposed  pneumonia  of  a  year 
ago,  are  suggestive  of  cardiac  mischief  and  pulmonary  congestion. 
Nocturia  points  in  the  same  direction.  Hemoptysis  in  such  a  patient, 
followed  immediately  by  dropsy  of  the  legs,  is  excellent  evidence  that 
the  heart  is  the  source  of  the  trouble. 

The  pulmonary  signs  in  the  lungs  are  equivocal.  They  are  con- 
sistent either  with  tuberculosis  or  with  pulmonary  congestion  and 
infarction.  The  existing  anemia  is  presumably  of  the  posthemor- 
rhagic type. 

In  the  heart  and  vessels  we  have  evidence  of  arteriosclerosis  and, 
very  possibly,  contracted  kidney.  In  my  experience  a  blood-pressure 
as  high  as  290  is  generally  the  result  of  a  combination  of  arterio- 
sclerosis with  chronic  glomerulonephritis,  both  of  the  ordinary  causes 
of  hypertension  acting  in  conjunction.  We  may  call  the  case  one  of 
pulmonary  apoplexy,  provided  we  recognize  that  this  does  not  differ- 
entiate it  from  the  infarctions  seen  in  young  persons  and  without  arterio- 
sclerosis. It  is  presumably  the  back  pressure  in  the  lung  or  the  slow 
circulation  through  its  vessels,  not  the  weakness  of  those  vessels,  that 
leads  to  the  infarct  and  hemorrhage. 


CHAPTER  X 

EDEMA  OF  THE  LEGS 

Edema  of  the  legs,  like  all  edemas,  has  three  main  causes — the 
heart,  the  kidney,  and  the  blood. 

(i)  Cardiac  edema  includes  not  only  the  obvious  lesions  of  the 
heart  valves  or  heart  wall,  but  also  the  swelling  of  the  feet  seen  so 
commonly  in  the  obese. 

(2)  The  edema  of  renal  disease  is  traditionally  believed  to  begin 
with  the  face  and  show  itself  later  in  the  feet.  This,  however,  is  not 
invariably  the  cause. 

(3)  In  anemia  the  edema  may  quite  possibly  be  of  the  cardiac 
variety,  i.  e.,  anemia  may  have  produced  cardiac  weakness  and  thus 
an  edema,  indirectly  rather  than  directly  due  to  the  blood. 

Besides  these  causes,  all  possibly  connected  with  the  first  of  them, 
the  only  common  type  is  the  slight  edema  of  the  hands  and  feet,  not 
infrequently  seen  in  hot  weather. 

LOCAL  CAUSES  OF  EDEMA 

Varicose  veins  are  by  far  the  commonest  cause  for  swelling  of  the 
legs.  Their  presence  is  usually  obvious  and  needs  no  discussion. 
Local  skin  disease,  involving  the  legs,  may  have  the  same  effects, 
usually  bilateral,  usually  making  clear  their  nature  by  the  ordinary 
signs  of  inflammation.  Phlebitis,  almost  invariably  unilateral,  may 
be  unaccompanied  by  pain  or  tenderness,  but,  as  a  rule,  there  is  sore- 
ness over  the  course  of  the  vein  on  the  inner  side  of  the  leg.  The  diag- 
nosis can  sometimes  be  made  only  by  study  of  the  associated  disease; 
for  instance,  typhoid  fever  or  the  puerperal  state.  An  enlargement 
or  edema  of  one  leg,  coming  on  in  either  of  these  conditions,  should 
always  be  assumed  to  be  due  to  phlebitis  until  proved  to  the  con- 
trary, whether  any  local  pain  or  tenderness  is  present  or  not.  Chill, 
fever,  and  leukocytosis  may  accompany  the  onset  of  such  a  phlebitis. 

Alcoholic  neuritis  is  a  cause  of  edema  often  forgotten.  It  is,  pre- 
sumably, akin  to  the  edema  seen  in  infectious  peripheral  neuritis 
(beriberi).  The  accompanying  loss  of  knee-jerks  and  changes  in 
sensation  usually  make  the  diagnosis  clear. 

Vol.  11—30  465 


466  DIFFERENTIAL  DIAGNOSIS 

In  cirrhosis  of  the  liver  an  edema  of  the  legs,  appearing  usually- 
subsequent  to  the  development  of  ascites,  is  the  rule.  How  far 
cardiac  and  renal  elements  enter  into  the  production  of  this  swelling 
it  is  often  impossible  to  determine  during  life. 

Hereditary  trophedema,  a  mysterious  condition  probably  akin  to 
elephantiasis,  offers  no  special  difficulty  in  diagnosis,  owing  to  the 
fact  that  it  is  present  from  the  time  of  birth.  It  rarely  affects  both 
legs,  and  it  is  usually  associated  with  some  thickening  of  the  sub- 
cutaneous tissues.  Myxedema  is  occasionally  associated  with  true 
edema  of  the  legs,  the  two  diseases  resulting  in  a  very  tough,  brawny 
enlargement,  very  puzzHng  at  first  sight.  The  coincident  changes  in 
the  face,  skin,  hair,  and  cerebration  should  make  the  diagnosis  clear. 

VARIETIES  AND  SITES  OF  EDEMA 

Swelling  of  the  legs  usually  appears  first  upon  the  front  of  the 
shin  and  the  back  of  the  thigh.  This  is  doubtless  due  to  the  arrange- 
ment of  the  blood-vessels.  At  the  very  beginning  of  an  edema  the 
shin  bones  are  often  notably  tender,  and  it  is  good  practice  in  mak- 
ing routine  physical  examinations  to  press  strongly  upon  the  shin 
bone  in  search  of  such  tenderness. 

Brawny  edema,  tough  and  difficult  to  indent,  usually  means  a 
relatively  long-standing  and  high  degree  of  dropsy,  but  it  is  also  de- 
pendent more  or  less  upon  the  quahty  of  the  tissues  in  which  it  accu- 
mulates. 

EDEMA  IN  CONVALESCENCE 

After  any  prolonged  illness,  such  as  typhoid  fever,  the  patient  is 
apt  to  show  edema  of  the  legs  when  he  first  gets  out  of  bed.  This 
may  persist  for  some  days  or  even  weeks,  but  ultimately  clears  up, 
and  should  occasion  no  alarm.  Doubtless  this  is  due  to  the  fact  that 
the  circulatory  system  cannot  at  first  accommodate  itself  to  the  greater 
strain  thrown  upon  it  by  the  perpendicular  position,  in  comparison 
with  the  previous  horizontal  position  of  the  body. 

Case  195 

A  brakeman  of  fifty- three  entered  the  hospital  October  24,  1903. 
For  six  months  the  patient  has  noticed  swelling  of  his  legs,  and  for 
about  four  weeks  some  enlargement  of  the  abdomen,  with  dyspnea,  and, 
of  late,  orthopnea.  Nocturia,  2  to  3.  Appetite  poor.  Bowels  normal, 
sleeps  well.  The  patient  takes  three  or  four  glasses  of  whisky  and 
three  or  four  of  ale  a  day.  He  had  typhoid  fever  at  eighteen  and  frac- 
ture of  the  skull  in  1876.     He  has  had  gonorrhea  twice;  denies  syphilis. 


Edema  of  the  Legs 


HEART  DISEASE  ■■■■■■■^^■^^^l^i^HBaii^l^^HH  8236 

NEPHRITIS  ■■■■^^^^B  2856 

ANEMIA  I^HB  923 

VARICOSE  VEINS  IHI  487 

PHLEBITIS'  ■  390 

CIRRHOSIS  OF  LIVER  ■  ^JOS- 

ALCOHOLIC  NEURITIS  I  16 

OBSTRUCTION       OFl  , 


VENA  CAVA  i 


4 


BERIBERI  I  2 

^  Affecting  almost  invariably  one  leg.     The  other  diseases  here  listed  affect  both 


467 


468  DIFFERENTIAL   DIAGNOSIS 

.  Physical  examination  showed  good  nutrition;  pupils,  glands,  and 
reflexes  normal.  Heart  and  lungs  negative,  except  for  diminished 
breathing  over  the  lower  quarter  of  the  left  back,  where  numerous 
crackling  rales  were  heard.  Abdomen  showed  shifting  dulness  in  the 
flanks  and  the  superficial  veins  were  rather  prominent.  The  girth, 
2  inches  above  the  umbiHcus,  was  44  inches.  Marked  edema  of  the 
legs.  The  urine  averaged  35  ounces  in  twenty-four  hours,  smoky, 
acid;  specific  gravity,  1020;  albumin,  |  per  cent.;  sediment,  much 
normal  blood,  numerous  hyaline,  fine  and  brown  granular  casts,  with 
blood  adherent.     Blood  negative. 

The  abdomen  was  tapped  on  the  28th  and  18  pints  of  straw- 
colored  fluid  withdrawn,  with  a  specific  gravity  of  1009.  The  urine 
continued  bloody.  The  abdomen  was  tapped  again  on  the  7  th  of 
November  and  an  equal  quantity  of  fluid  of  practically  the  same 
characteristics  was  evacuated.  After  this  tapping  the  edge  of  the  Hver 
was  felt  in  the  epigastrium.  For  a  few  days,  before  and  after  the  8th 
of  November,  there  was  a  shght  rise  of  temperature,  associated  with 
nausea  and  occasional  vomiting. 

Discussion. — The  patient  is  alcohoHc  and,  therefore,  very  possibly, 
s>phiKtic.  No  physician  should  put  any  weight  upon  the  negative 
statement  of  an  alcoholic  in  regard  to  syphihtic  infection.  His  state- 
ment may  well  represent  his  belief,  but  he  really  knows  nothing  about 
the  matter. 

The  patient's  dropsy  appeared  six  months  ago  in  the  legs,  and  only 
a  month  ago  in  the  belly.  Nevertheless,  the  liver  must  first  be  sus- 
pected as  a  cause  of  the  edema,  because  of  the  enlarged  veins  visible 
over  the  abdomen,  the  palpable  Hver  edge,  and  the  alcoholic  history. 

The  condition  of  the  urine  makes  it  probable  that  some  degree  of 
nephritis  exists,  either  acute  or  acute  exacerbation  of  a  chronic  proc- 
ess. The  low  specific  gravity  of  the  ascitic  fluid  may  be  taken  as  ex- 
cluding tuberculous  or  cancerous  peritonitis,  and,  as  the  heart  shows 
nothing  of  note,  we  may  conclude  that  the  edema  is  of  hepatic  origin, 
renal  origin,  or  due  to  both  sources  at  once.  Unfortunately,  we  have 
no  record  of  a  blood-pressure  measurement  to  confirm  our  diagnosis 
of  nephritis;  in  1903  such  measurements  were  not  a  routine. 

Outcome. — After  November  8th  the  ascites  returned  more  slowly 
than  before,  and  he  did  not  have  to  be  tapped  again  before  he  left  the 
hospital  on  the  21st  of  November.  The  urine  at  this  time  showed 
very  few  casts,  but  still  contained  a  large  trace  of  albumin  and  had  a 
good  deal  of  normal  blood  in  the  sediment. 


EDEMA   OE   THE   LEGS  469 

Case  196 

A  farmer  of  seventy-seven  entered  the  hospital  May  4,  1904. 
The  patient  has  a  negative  family  history,  and  has  always  been  very 
strong  and  rugged,  except  for  an  attack  of  sciatica  in  1885  and  a  second 
attack  six  months  ago,  lasting  five  weeks.  After  this  the  left  great 
toe  and  the  side  of  the  foot  remained  numb  and  have  been  so  ever 
since. 

A  week  ago,  while  dressing,  he  noticed  that  his  left  foot  was  swollen. 
This  has  gradually  spread  up  the  leg  and  tenderness  has  appeared  here 
and  there;  in  other  respects  he  feels  perfectly  well.  Appetite,  bowels, 
and  sleep  are  normal. 

Physical  examination  is  negative,  save  that  the  left  leg  and  thigh 
are  swollen^  slightly  reddened,  and,  along  the  course  of  the  internal 
saphenous  vein,  tender  on  pressure.  Blood  and  urine  normal.  The 
temperature  during  the  first  week  rose  to  99.5°  F.  each  night,  falling 
to  normal  in  the  morning. 

Discussion. — Edema  of  one  leg  narrows  the  field  of  consideration 
at  once.  We  must  be  dealing  with  a  local  cause.  The  recent  his- 
tory of  pain  and  numbness  in  the  left  leg  in  a  man  of  his  age  leads 
us  to  surmise  that  arteriosclerosis  ma^have  something  to  do  with  his 
troubles.  The  residual  numbness  of  the  foot  may  possibly  be  at- 
tributed to  this  cause. 

Nevertheless,  we  must  reckon  with  an  acute  affair  in  addition  to 
the  long-standing  malady.  Something  has  happened  within  the  past 
week,  and  that  something  bears  all  the  marks  of  a  phlebitis.  The 
local  redness  and  tenderness  such  as  is  here  described  is  produced, 
so  far  as  I  know,  by  nothing  except  phlebitis  with  the  accompanying 
thrombus.  Were  the  tenderness  less  accurately  limited  one  might 
have  to  consider  l3miphangitis,  erysipelas,  or  a  diffuse  cellulitis,  a  trio 
of  lesions  which  in  the  leg  may  melt  into  each  other  in  a  way  to  make 
sharp  diagnostic  distinctions  valueless. 

Doubtless  the  underlying  arteriosclerosis  and  the  malnutrition 
resulting  from  it  have  something  to  do  with  the  acute  phlebitis,  but 
just  what  the  connection  is  I  do  not  know.  Phlebosclerosis  might  be 
a  possible  intermediary  link,  but  the  physical  examination  does  not 
confirm  it. 

Outcome. — Under  poulticing  and  salicylate  of  sodium  the  swelling 
and  tenderness  were  gone  from  the  leg  by  the  15th  of  May;  by  the 
20th  of  May  he  seemed  perfectly  well  and  was  allowed  to  go  home. 


470  DIFFERENTIAL   DIAGNOSIS 

Case  197 

A  man  of  fifty-eight,  employed  in  a  paper-mill,  entered  the  hospi- 
tal August  II,  1904.  For  four  months  the  patient  has  had  pain  and 
sweUing  in  both  feet,  worse  on  standing.  In  other  respects  he  feels 
well,  though  he  has  used  alcohol  to  excess  up  to  four  months  ago. 
His  family  history  and  past  history  are  negative.  His  knee-jerks 
were  not  obtained.  Both  ankles  were  somewhat  reddened  and 
somewhat  swollen,  the  arches  of  both  feet  broken  down,  some  var- 
ices about  the  ankles. 

Physical  examination,  including  the  blood  and  urine,  was  other- 
wise negative. 

Discussion. — Alcohohc  neuritis  is  probably  the  cause  of  the  lack 
of  knee-jerks  in  this  case,  and  if  the  edema  were  spread  more  widely 
over  the  legs  the  neuritis  would  probably  be  accountable  for  that 
also.  It  is  notable,  however,  that  the  redness  and  swelling  of  which 
he  complains  are  confined  to  the  region  of  the  ankles  and  are  asso- 
ciated ^vith  pronated  feet. 

This  combination  of  inflammatory  and  mechanical  changes  about 
the  tarsus  is  a  condition  commonly  seen  and  not  well  understood.  Is 
the  flat-foot  the  cause  of  the  inflammation  or  the  inflammation  the 
cause  of  the  flat-foot?  The  latter  seems  more  probable,  yet  in  some 
cases  the  flat-foot  seems  to  precede  the  inflammation.  On  the  other 
hand,  treatment  of  the  flat-foot  is  often  the  quickest  means  of  reliev- 
ing the  inflammation.  Rest  and  salicylates  do  something,  but  do  not 
finish  up  the  job.     Local  measures  of  relief  are  the  essential  thing. 

It  must  be  assumed  that  the  cardiac,  renal,  and  hemic  causes  of 
dropsy  are  ruled  out  by  the  physical  examination  in  this  case ;  also  the 
more  obvious  superficial  and  local  causes  of  edema,  such  as  varicose 
veins. 

Why  do  people  get  flat-foot?  The  ordinary  mechanical  explana- 
tions do  not  sufl&ce.  The  people  who  are  most  on  their  feet  are  not 
always  those  who  get  flat-foot.  Physiologic  factors  of  nutrition  and 
general  vitahty,  whatever  that  means,  are  certainly  of  importance. 
The  people  who  lose  sleep,  eat  irregularly,  subject  themselves  to  all 
sorts  of  bodily  and  mental  strain  are  especially  predisposed  to  this 
apparently  quite  local  affection. 

Outcome. — He  was  fitted  with  flat-foot  plates  and  left  the  hospital 
on  the  24th  of  August.     The  diagnosis  reads,  flat-foot  and  no  home. 


EDEMA   OF   THE   LEGS 


471 


Case  198 

A  cook  of  j&fty  first  entered  the  hospital  March  16,  1908.  He 
entered  the  hospital  the  second  time  February  6,  1909,  having  been 
working  since  his  discharge,  April  8,  1908.  For  the  past  month  he  has 
served  as  a  cook  in  a  lumber  camp  and  has  felt  well  and  strong, 
though  he  noticed  that  his  legs  had  begun  to  swell  and  his  face  to  grow 
pale.  For  the  past  two  or  three  weeks  he  has  also  noticed  much 
weakness.  Three  weeks  ago  his  bowels  became  more  costive  than 
usual.  A  week  later  he  noticed  that  the  fecal  discharges  were  very 
irritating  to  the  skin.     This  condition  he  has  noticed  many  times  be- 


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fore.  Ten  days  ago  his  appetite  failed,  but  he  worked  until  four  days 
ago.  He  has  had  a  little  pain  across  the  small  of  his  back  of  late, 
possibly  caused  by  a  strain  when  carrying  a  quarter  of  beef  which 
weighed  260  pounds.  He  has  lost  no  weight.  At  the  present  time 
his  bowels  are  regular. 

Physical  examination  showed  poor  nutrition,  marked  pallor. 
The  apex  first  sound  of  the  heart  was  sharp,  and  was  followed  by  a 
systolic  murmur  transmitted  to  the  axilla.  A  harsher  systolic  was 
heard  over  the  pulmonary  area.  Visceral  examination  was  otherwise 
negative.  There  was  moderate  edema  of  the  legs  and  thighs.  For 
the  first  two  weeks  of  his  stay  in  the  hospital  the  temperature  ranged 


472  DIFFERENTIAL  DIAGNOSIS 

as  shown  in  Fig.  172.  His  urine  was  of  low  gravity,  but  otherwise 
negative.  The  red  cells  at  entrance  numbered  900,000,  and  white, 
2000.  Hemoglobin,  40  per  cent.  There  was  moderate  deformity  of 
the  cells,  with  stippling  and  discoloration.  Nucleated  red  cells  were 
occasionally  seen,  the  normoblast  type  always  predominating.  The 
patient  remained  a  month  in  the  hospital,  during  which  time  his  red 
cells  rose  to  2,250,000,  his  white  to  6000,  his  hemoglobin  to  70  per 
cent.  The  number  of  oversized  red  cells  grew  more  and  more  marked, 
but  at  the  time  of  his  discharge  there  was  no  stippling,  no  abnormal 
staining  of  the  red  cells,  and  practically  no  deformities.  During  the 
last  ten  days  of  his  stay  he  passed  a  large  amount  of  urme  and  the 
edema  disappeared  from  his  legs.  He  left  the  hospital  February  10, 
1909. 

Discussion. — Although  the  blood  in  this  case  makes  a  diagnosis 
of  pernicious  anemia  almost  inevitable,  one  hesitates  for  a  moment 
when  one  notes  that  he  has  been  working  hard  until  within  four  days. 
A  moment's  reflection,  however,  reminds  us  that  this  is  one  of  the 
peculiarities  of  pernicious  anemia,  that  the  patient's  working  strength 
may  continue  despite  a  degree  of  anemia  which  makes  it  seem  almost 
inconceivable  that  the  patient  should  be  out  of  bed. 

In  the  present  case  there  should  have  been  no  doubt  about  the 
diagnosis,  because  such  marked  pallor  would  have  attracted  attention 
at  once  and  led,  in  all  probability,  to  a  blood  examination.  But  if 
this  patient  had  been  one  of  the  10  per  cent,  of  pernicious  anemia 
cases,  which  are  not  pale  but  show  a  perfectly  normal  complexion, 
the  diagnosis  would  surely  have  been  missed  by  anyone  not  accustomed 
to  make  some  blood  test  as  a  matter  of  routine.  Even  the  hemo- 
globin test  will  not  always  set  us  on  the  right  track  in  this  case,  for 
owing  to  the  high  color  index  the  hemoglobin  is  often  but  Httle 
lowered. 

It  may  be  well  to  recall  in  this  connection  that  cases  of  pernicious 
anemia  may  come  to  us  in  many  strange  disguises.  They  may  appear 
without  any  symptoms  suggesting  anemia  and  with  complaints  merely 
of  paralysis  in  the  legs — a  paralysis  of  the  spastic  type.  Another 
type  of  the  same  disease  appears  with  fever  as  the  presenting  symptom, 
so  that  typhoid  fever  is  not  infrequently  the  first  diagnosis  made. 
Others  begin  with  diarrhea,  and  any  anemia  that  is  recognized  is  apt 
to  be  falsely  attributed  to  the  diarrhea,  when  the  etiologic  sequence 
is  really  in  the  other  direction.  The  majority  of  all  cases,  however, 
are  distinguished  by  the  fact  that  they  present  themselves  com- 
plaining of  one  symptom  only — viz.,  weakness,  a  weakness  unparal- 


EDEMA   OF   THE   LEGS  473 

leled  in  any  other  disease,  because  it  is  not  associated  with  pain^  loss  of 
weight,  or  functional  disturbances,  such  as  almost  invariably  accom- 
pany any  other  disease  producing  a  similar  degree  of  prostration. 

Outcome. — His  previous  entry,  March,  1908,  had  shown  practi- 
cally the  same  signs  and  course,  his  red  cells  rising  on  that  occasion 
from  1,000,000  to  3,000,000  within  two  weeks.  This  was  apparently 
his  first  attack,  but  he  rapidly  relapsed  and  died  August  14,  1909. 

Case  199 

A  schoolboy  of  eleven  entered  the  hospital  June  4,  1909.  The 
child  has  not  felt  well  for  a  week  and  has  complained  of  headache  and 
abdominal  pain.  These  are  both  gone  now.  His  appetite  is  good, 
bowels  loose.  At  times  he  has  spoken  of  chilliness.  There  is  nothing 
else  of  interest  in  his  history. 

On  physical  examination  the  boy  did  not  look  sick.  The  chest 
and  abdomen  were  negative.  Urine  negative.  White  cells,  12,400. 
No  Widal  reaction.  No  eosinophils.  The  case  was  considered  one  of 
typhoid  fever,  though  the  boy  seemed  unusually  bright  and  active. 
Blood-pressure  was  normal.  Skin  tuberculin  reaction  negative.  On 
the  6th  there  was  slight  stiffness  of  the  neck  and  Kernig's  sign  was 
present  on  both  sides.  The  next  day  muscular  tenderness  and  pufl&- 
ness  about  the  eyes  suggested  trichiniasis,  but  there  was  no  eosino- 
philia.  On  the  nth  a  spinal  puncture  was  done  and  10  c.c.  of  clear 
fluid  obtained,  containing  no  cells  or  bacteria.  On  the  12th  the  heart's 
apex  extended  a  centimeter  beyond  the  nipple  line,  and  there  was  a 
slight  systolic  murmur  which  led  us  to  suspect  acute  endocarditis. 
The  reactions  with  two  different  strains  of  paratyphoid  were  negative. 
The  fundus  oculi  was  examined  and  found  normal.  The  middle  ears 
were  apparently  normal. 

Discussion. — Fever  without  known  cause  in  a  boy  of  eleven  is  most 
often  due  to  tuberculosis.  When  I  say  "without  known  cause,"  I 
mean  without  any  local  lesion,  such  as  an  exanthem,  a  sore  throat,  a 
tj^hoid  infection,  or  a  septic  focus. 

In  the  present  case  typhoid  seemed  at  first  the  most  probable  diag- 
nosis, although  the  Widal  reaction  was  negative  and  the  white  cells 
somewhat  increased.  When  later  the  neck  became  stiff  and  the 
hamstring  muscles  contracted  we  thought  of  meningitis,  and  tried  to 
get  proof  of  the  diagnosis  through  lumbar  puncture.  This  pro\dng 
negative,  we  looked  for  a  confirmatory  evidence  of  trichiniasis,  but  the 
persistent  absence  of  eosinophilia  made  it  difiicult  to  confirm  such  a 
hypothesis.     I  feel  sure  but  for  the  house  officer's  unusual  persistence 


474 


DIFFERENTIAL   DIAGNOSIS 


we  never  should  have  discovered  any  eosinophiha  in  this  case.  Why 
the  blood  changes  appeared  so  late  I  have  no  idea.  Had  we  been 
unable  to  get  a  bit  of  calf  muscle,  the  diagnosis  might  well  have  been 
missed,  or  the  case  might  have  been  put  down  as  one  of  those  mys- 
terious instances  of  nephritis  without  albuminuria,  which  are  met  with 
now  and  then  in  literature. 

I  have  no   explanation  of   the  marked  general  edema  seen  in 
this  case.     It  was   as   striking  as   that  of   topical   acute  nephritis, 


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in  Case  199. 


yet  the  urine  gave  no  support  to  any  such  idea.  Edema  is,  of  course, 
the  rule  in  trichiniasis,  but  it  is  usually  confined  to  the  region  of  the 
eyes. 

Outcome. — On  the  17th  a  bit  of  calf  muscle  was  excised  and 
abundant  trichinae  were  found.  There  was  no  infiltration  of  eosino- 
phils about  the  parasites.  Up  to  this  time  there  had  been  no  eosino- 
phiha in  the  blood.  On  the  2 2d  of  June  eosinophilia  appeared  for  the 
first  time.     On  the  4th  of  July  he  developed  general  edema,  involving 


EDEMA   OF   THE   LEGS 


475 


the  hands,  legs,  back,  and  abdominal  wall.     The  course  of  the  eosino- 
philia  is  shown  in  Fig.  173.     The  temperature  range  is  also  of  inter- 


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Fig.  174. — Temperature  range  in  Case  199. 

est  (Fig.  174).     By  the  20th  of  July  he  was  up  and  about,  and  on 
the  31st  was  discharged,  the  eosinophiHa  still  continuing. 

Case  200 

A  child  of  four  years  entered  the  hospital  February  14,  1910. 
Four  days  ago  the  child  began  to  complain  of  pain  and  swelling  in  her 
legs,  said  she  felt  tired,  and,  later,  fainted.  At  the  present  time  she 
has  pain  in  the  pit  of  the  stomach,  in  the  calves,  and  the  heels.  This 
morning  her  face  became  swollen.  Her  appetite  has  been  poor  for 
six  months,  and  for  three  weeks  she  has  eaten  almost  nothing.  The 
patient's  father  died  of  tuberculosis  and  her  mother  at  this  child's 
birth.  The  child  was  said  to  have  had  tuberculosis  of  the  kidneys 
when  very  young,  and  when  two  years  old  had  sores  all  over  her 
hands. 

Physical  examination  shows  poor  nutrition,  heart's  impulse  in  the 
fifth  space,  2^  cm.  outside  the  nipple  hne,  the  right  border  2  cm.  from 
midsternum.  A  late  diastoHc  murmur  was  heard  at  the  apex  and, 
later,  a  systoHc  murmur  also.  Pulmonic  second  sound  was  accentu- 
ated. In  the  middle  of  the  left  back  there  were  slight  dulness  and 
bronchovesicular  respiration.  The  liver  dulness  extended  from  the 
sixth  rib  to  a  point  2^  cm.  below  the  ribs,  but  the  edge  was  not  felt. 


476 


DIFFERENTIAL   DIAGNOSIS 


At  entrance  the  white  cells  numbered  38,000,  from  which  point  they 
gradually  decreased  to  17,000,  ^Nlarch  14th.  The  urine  was  negative, 
likewise  the  stools.  By  the  13th  of  March  the  heart  was  perfectly 
regular  and  much  slower  than  at  entrance.  Although  the  child  was 
somewhat  anemic,  she  was  allowed  to  go  home  on  the  24th. 

She  re-entered  ]March  8,  191 1.  During  the  year  that  had  passed 
the  child  had  seemed  perfectly  well,  and  had  run  about  as  actively  as 
ever.  For  six  weeks  she  had  now  complained  of  being  tired  and  for 
four  days  had  been  in  bed,  dozing,  moaning,  and  unable  to  eat.  At 
this  time  there  was  a  systolic  murmur  at  the  apex  and  a  diastolic  on 

the  left  edge  of  the  sternum. 
The  pulse  had  a  Corrigan 
quality. 

She  rapidly  improved,  the 
pulse  and  respiration  coming 
down  as  shown  in  Fig.  175. 
She  was  discharged  on  the 
24th. 

Discussion.  —  Unfortun- 
ately, no  Wassermann  reac- 
tion was  done.  Without  this 
we  cannot  exclude  syphiUs 
with  certainty,  but  as  there 
is  no  positive  evidence  of 
that  disease  we  may  reason- 
ably assume  that  the  other 
common  cause  of  cardiac 
lesions  in  young  children — 
namely,  a  rheumatic  or  strep- 
tococcic endocarditis — is  the 
correct  diagnosis. 
The  notable  point  is  the  extraordinarily  high  respiration,  100  per 
minute,  as  recorded  at  the  time  of  entrance,  and  the  gradual  fall  of 
this  rate,  which  required  a  full  week  to  reach  normal  (Fig.  175). 

Outcome. — March  8,  191 1,  the  child  entered  the  hospital  again, 
with  a  clear  case  of  aortic  and  mitral  endocarditis. 

April  6,  1913,  she  reported  at  the  Out-patient  Department.  She  is 
now  going  to  school  regularly  and  has  no  cardiac  symptoms.  The 
heart's  apex  is  in  the  fifth  space,  7  cm.  from  the  median  line.  Save  for 
a  soft  diastolic  murmur,  loudest  over  the  third  left  costal  cartilage,  the 
heart  shows  nothing  abnormal. 


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fall  in  the  respiration.  The  star  near  the  figure 
70  stands  for  the  systolic  blood-pressure. 


EDEMA   OF   THE   LEGS 


Case  201 


477 


A  saw-filer  of  thirty-one  entered  the  hospital  January  26,  1910. 
November  30th,  following  an  active  half  hour  after  breakfast,  he  sud- 
denly vomited  "3  quarts"  of  food  and  dark  clotted  blood.  After  this 
he  felt  dizzy  and  weak,  but  worked  until  three  o'clock,  when  he  went 
home  and  again  vomited  food  and  bright  blood.  In  the  four  days 
following  he  vomited  blood  six  times,  losing  consciousness  with  the 
last  hemorrhage.  He  had  tarry  stools  during  this  attack.  Since  the 
5th  of  December  he  has  had  no  more  hemorrhages,  but  soon  after  that 
date  he  had  a  cramp-like  pain  in  the  bottom  of  his  left  foot.  Tender- 
ness appeared  in  the  inside  of  the  ankle,  and  shifted  up  the  inside 


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of  the  leg  to  the  groin  in  the  course  of  the  next  seven  weeks.  Most  of 
the  pain  at  the  present  time  is  in  the  groin.  Coincidently  with  this 
pain,  the  whole  leg  has  been  swollen.  For  the  past  week  he  has  had 
night-sweats;  for  the  past  two  weeks,  a  cough  and  poor  appetite.  He 
sleeps  well;  since  last  summer  has  lost  40  pounds. 

The  onset  of  these  symptoms  was  practically  acute,  though  he 
had  noticed  some  distress  in  the  epigastric  region  before  and  after 
meals  for  five  years.  Otherwise  his  family  history  and  past  history 
are  good.     His  habits  excellent. 

The  course  of  the  patient's  temperature  is  shown  in  Fig.  176. 
At  entrance  his  blood  showed  3,100,000  red  cells,  and  during  his 


478  DIFFERENTIAL   DIAGNOSIS 

stay  this  gradually  rose  to  3,500,000.  Hemoglobin  gained  during 
that  period  from  60  per  cent,  at  entrance  to  70  per  cent,  at  discharge. 
The  white  cells  showed  nothing  abnormal.  There  was  moderate 
achromia  at  all  times.  The  urine  was  normal.  There  was  no  blood 
in  the  feces  at  any  time.  The  heart's  apex  extended  2  cm.  outside  the 
nipple  line;  the  right  border  3  cm.  beyond  midsternum.  There  was  a 
soft  systolic  murmur  in  the  pulmonary  area,  otherwise  the  organ  was 
normal. 

The  left  foot  was  reddened  and  edematous,  and  from  the  knee  to 
the  groin  an  irregular  cord-like  mass  was  palpable  on  the  inner  side 
of  the  thigh.  The  left  groin  was  reddened  and  edematous  and  a 
large  mass  was  felt  in  the  midinguinal  region ;  also  at  a  point  2  inches 
above  the  pubic  bone,  midway  between  the  median  Hne  and  Poupart's 
ligament,  a  small  tender  mass  was  indistinctly  felt. 

On  the  31st  the  patient  was  seized  during  the  night  with  a  sudden 
sharp  pain  in  the  back  of  the  left  lower  chest.  Morphin  was  required. 
Next  morning  feeble  respiration  and  a  few  moist  rales  were  detected 
in  a  small  area  in  the  left  back.  The  edema  of  the  foot  thereafter 
steadily  diminished,  and  by  the  13th  of  February  was  gone.  On  the 
15th  there  was  a  sharp  rise  in  the  temperature,  headache,  nausea,  and 
pain  in  the  right  leg.  The  left  leg  was  then  apparently  well,  and  the 
right  leg  showed  nothing  but  tenderness  in  the  popliteal  space.  This 
lasted  until  the  first  of  March,  when  he  seemed  to  be  perfectly  well  and 
went  home  with  both  legs  bandaged. 

Discussion. — What  is  the  probable  relation  between  the  hematem- 
esis  and  melena  with  which  this  patient's  illness  began  and  the  sub- 
sequent edema  and  pain  in  the  left  leg? 

It  seems  to  me  probable  that  the  slowing  of  circulation  and  de- 
pression of  vitaHty  which  the  hemorrhage  brought  about  favored  the 
occurrence  of  phlebitis.  That  process  showed  in  this  case  more  than 
the  usual  evidence  of  its  infectious  origin ;  but  there  is  much  to  persuade 
us  that  most,  if  not  all,  cases  of  phlebitis  have  an  infectious  factor  in 
their  causation.  Very  few  cultures  made  from  thrombi  have  ever 
proved  sterile.  The  anorexia,  sweats,  and  prostration  are  doubtless 
due  to  this  infectious  element  in  combination  with  the  weakness  in- 
duced by  loss  of  blood. 

All  this,  however,  does  not  explain  why  he  has  lost  40  pounds  in 
the  past  six  months.  Were  any  evidence  of  hepatic  cirrhosis  present, 
we  might  easily  account  'in  this  way  for  the  loss  of  weight,  for  the 
hemorrhage,  and  the  subsequent  phlebitis;  but,  in  point  of  fact,  we 
have  not  a  scrap  of  evidence  on  which  to  incriminate  the  liver. 


EDEMA   OF   THE   LEGS  479 

The  later  chapters  of  this  patient's  history  are  to  be  explained  by  a 
migration  or  recurrence  of  thrombosis  in  other  veins,  first  in  the  lung, 
later  in  the  right  leg.  Such  recurrent  attacks  of  phlebitis  are  some- 
times extraordinarily  tedious  and  discouraging.  They  may  occur  in 
perfectly  healthy  people — in  my  experience  generally  males — and  flit 
from  vein  to  vein  without  cause  or  cessation  for  a  year  or  more.  In 
the  end  the  whole  process  usually  clears  up  and  leaves  good  health 
behind  it,  but  from  the  point  of  view  of  therapeutics  we  are  distress- 
ingly helpless. 

Outcome. — June  4,  1913,  he  writes,  "I  am  not  what  you  would 
call  a  well  man,  but  I  am  trying  to  get  by  with  the  rest.  In  January, 
1 913,  a  surgeon  removed  the  veins  from  both  my  legs,  but  they  did 
not  come  out  very  weU." 

Case  202 

A  butler  of  twenty-six  entered  the  hospital  June  i,  19 10.  Five 
weeks  ago  the  patient's  ankles  were  swollen  for  a  few  days.  Three 
weeks  ago  the  swelHng  returned  and  traveled  up  the  legs  and  thighs 
to  the  abdomen,  hands,  face,  and  the  top  of  his  head.  Except  for 
this  he  has  no  symptoms  and  feels  perfectly  well,  although  he  has 
noticed  for  the  past  few  days  some  shortness  of  breath  on  exertion. 
His  ordinary  weight  is  155  pounds;  now,  172  pounds.  Except  for  a 
soft,  low-pitched  murmur  at  the  heart's  apex  the  chest  is  negative. 
There  is  marked  edema,  as  described  by  the  patient.  Systolic  blood- 
pressure,  during  most  of  the  four  weeks  in  the  ward,  varied  between 
140  and  150.  The  highest  reading  was  170  mm.  Hg. ;  the  lowest, 
120  mm.  Hg.  He  was  afebrile  throughout  the  month  of  observation. 
The  Wassermann  reaction  was  negative. 

The  urine  averaged  35  ounces  in  twenty-four  hours,  was  of  normal 
color,  slightly  cloudy;  specific  gravity,  1018  to  1023;  albumin  from 
I  to  1.8  per  cent.  The  sediment  showed  many  hyahne  and  granular 
casts  with  a  Httle  fat  and  a  few  cells  adherent.  Blood  showed  at 
entrance  23,000  white  cells,  with  a  polynuclear  leukocytosis.  This 
disappeared  within  a  few  days.  The  stools  showed  ova  and  Hve 
embryos  of  Strongyloides  intestinalis,  also  a  feW  eggs  of  Trichiuris 
trichiuria.  He  did  not  improve  much  during  the  month  in  the  ward, 
though  his  edema  readily  disappeared  when  he  stayed  in  bed.  Con- 
centrated magnesium  sulphate  solution,  hot-air  baths,  pilocarpin, 
and  salt-free  diet  had  no  considerable  effect. 

He  left  the  hospital  on  the  27th  of  June,  and  re-entered  on  the  13  th 
of  July  in  practically  the  same  condition.     At  this  time  the  abdomen 


480  DIFFERENTIAL  DIAGNOSIS 

had  to  be  tapped,  and  a  quart  of  chyliform  fluid  was  obtained  which 
had  a  specific  gravity  of  1006.  Examination  of  the  fluid  by  Dr. 
W.  F.  Boos  showed  the  turbidity  to  be  due  to  pseudomucin.  There 
was  no  fat  present.  The  sediment  was  mostly  lymphocytes  and  endo- 
thehal  cells.  He  had  the  same  parasites  in  the  intestine  and  also  a 
varying  number  of  adult  hookworms  and  their  eggs. 

Discussion. — Bilateral  edema,  associated  with  dyspnea,  well- 
marked  urinary  changes,  and  a  slight  increase  of  blood-pressure,  is 
probably  renal  in  origin,  especially  as  it  is  associated  with  such  a  rapid 
gain  in  weight.  When  there  is  any  possibility  of  renal  or  cardiac 
disease  a  gain  of  weight,  which  we  ordinarily  welcome,  should  be 
viewed,  as  the  politicians  say,  with  alarm. 

The  only  thing  to  confuse  the  diagnosis  in  this  case  is  the  presence 
of  three  different  intestinal  parasites  and  of  a  somewhat  atypical  fluid 
obtained  by  tapping  the  abdomen.  Neither  of  these  facts,  however, 
is  of  any  importance.  Intestinal  parasites  cannot  possibly  have  any- 
thing to  do  with  the  production  of  edema.  Only  the  blood  parasite 
of  filaria  can  produce  edema,  when  it  blocks  the  lymphatics. 

The  presence  of  pseudomucin,  rendering  ascitic  fluid  milky  in  ap- 
pearance, is  a  spectacular  event,  often  exploited  with  great  satisfac- 
tion in  clinics,  but  of  no  practical  importance  as  far  as  is  known  at  the 
present  time. 

A  point  of  interest  in  the  case  is  the  blood-pressure  record.  The 
vast  majority  of  blood-pressure  readings  are  either  normal  or 
notably  increased.  Border-line  readings,  such  as  150,  are  rare,  a 
fortunate  thing  for  our  diagnoses.  This  means  that  there  is  usually 
no  disturbance  of  function,  no  symptom  that  brings  the  patient  to 
his  physician  until  the  hypertension  has  reached  a  notable  degree. 
Whether  it  takes  months  or  years  to  convert  a  normal  blood-pressure 
into  an  elevated  one  in  cases  of  chronic  nephritis  or  arteriosclerosis 
we  have  no  means  of  knowing,  but  there  are  certain  facts  reported 
by  the  life  insurance  companies  which  lead  me  to  believe  that  the 
change  may  be  a  relatively  sudden  one. 

If  this  is  true,  it  would  help  to  explain  the  fact  that  we  so  seldom 
see  the  patient  when'  his  blood-pressure  is  slightly  or  doubtfully  ele- 
vated. 

Outcome. — Blood-pressure  ranged  between  140  and  150  mm.  Hg. 
for  three  weeks.  The  urine  was  practically  the  same  as  during  his 
previous  entry.  Diagnosis:  Chronic  glomerulonephritis.  He  left  the 
hospital  on  the  29th  of  July. 


EDEMA   OF   THE   LEGS  48 1 

Case  203 

A  clerk  of  fifty-three  entered  the  hospital  June  3,  19 10.  The 
patient  denies  venereal  disease,  and  has  never  been  under  a  doctor's 
care  before.  He  has  taken  five  or  six  whiskies  and  five  or  six  beers 
a  day  for  thirty-five  years.  For  a  month  and  a  Jialf  his  legs  have  been 
slightly  sore  and  swollen,  and  for  five  or  six  weeks  he  has  noticed  some 
shortness  of  breath.  Yesterday  he  had  a  dizzy  spell  and  has  had 
several  more  since. 

On  physical  examination  the  patient's  pupils  did  not  react  to 
light.  There  were  blotchy  pigmented  areas  scattered  over  his  face 
and  forehead.  The  heart's  apex  extended  i|  cm.  outside  the  nipple 
line.  The  sounds  were  very  irregular  in  force  and  frequency  and 
were  of  poor  quality.  Pulses  were  equal,  irregular,  of  poor  volume 
and  tension.  Pulmonic  second  accentuated,  occasionally  a  sHght 
systolic  murmur  heard  at  the  apex.  The  abdomen  measured  97  cm. 
the  largest  circumference,  and  was  markedly  dull  in  the  flanks,  the 
dulness  shifting  with  change  of  position.  Knee-jerks  were  not  ob- 
tained. There  was  marked  edema  of  the  legs  and  thighs.  Systolic 
blood-pressure  was  130.  Blood  and  urine  normal.  Laryngoscopic 
examination  showed  abductor  paralysis  of  both  vocal  cords. 

Discussion. — In  an  alcoholic  any  leg  edema  is  suspected,  first 
of  all,  of  being  due  to  neuritis,  but  in  this  case  we  have,  in  addition, 
an  ascites  suggesting  a  possible  cirrhosis,  especially  in  a  man  of  his 
habits.  Moreover,  we  have  all  the  evidences  of  a  weakened  heart. 
SyphiHs  is  more  than  possible  in  any  patient  with  such  a  history. 
Unfortunately,  we  have  no  Wassermann  reaction,  but  it  may  well 
be  that  both  the  heart  and  the  Hver  have  been  affected  by  this  disease. 
Since  the  knee-jerks  are  not  obtained,  and  the  pupils  fail  to  react 
alike,  there  is  additional  reason  for  suspecting  syphiHs  and  tabes 
dorsalis  as  fundamental  causes  of  all  his  troubles.  Whether  the 
heart  or  the  Uver  is  chiefly  at  fault  we  cannot,  from  the  facts  be- 
fore us,  determine.  The  abductor  paralysis  is  doubtless  of  syphilitic 
origin. 

Outcome. — Intubation  was  considered,  but  not  done.  Later  in 
the  day  tracheotomy  was  obviously  necessary  and  was  done  by 
Dr.  Mosher.     He  died  soon  after. 

Case  204 

A  maid  employed  in  the  hospital,  thirty-seven  years  old,  entered 
the  ward  July  31,  19 10.     She  has  noticed  for  a  week  that  her  legs  were 

Vol.  11—31 


482 


DIFFERENTIAL  DIAGNOSIS 


swollen,  slightly  tender,  and  slightly  painful  on  walking.     At  first  the 
right  leg  was  more  swollen  than  the  left;  now  the  reverse  is  true.     She 

has  absolutely  no  symptoms,  though  the 
nurses  say  that  she  has  been  inefiicient  in 
her  work  of  late. 

Physical  examination  is  wholly  nega- 
tive, except  that  the  legs  and  ankles  are 
moderately  swollen,  the  skin  red,  glazed, 
and  markedly  tender.  Blood  and  urine 
normal. 

Discussion. — The  general  causes  of 
edema  are  obviously  absent.  Just  what 
the  local  cause  may  be  it  is  not  so  easy  to 
say,  but  certainly  some  cutaneous  or  sub- 
cutaneous disease  is  the  cause  of  the 
edema.  The  absence  of  leukocytosis 
makes  it  improbable  that  any  erysipelas 
or  cellulitis  was  present.  Further  than 
that,  without  special  dermatologic  knowl- 
edge, we  cannot  go. 

Outcome. — A  dermatologic  consultant 
pronounced  the  trouble  erythema  multiforme  in  a  stage  of  convales- 
cence. By  the  12th  of  August  the  whole  trouble  had  disappeared. 
The  range  of  the  temperature  is  shown  in  Fig.  177. 


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Case  205 

A  fireman  of  twenty-nine  entered  the  hospital  July  12,  1910. 
A  month  and  a  half  ago  the  patient's  right  ankle  and  calf  became 
swollen.  He  felt  perfectly  well  in  every  other  way,  and  this  swelling 
disappeared  in  four  days.  Two  weeks  ago  both  legs  swelled.  This 
has  continued  since,  although  he  has  absolutely  no  other  symptoms 
and  feels  perfectly  well.  He  has  had  no  hereditary  taints  and  no  pre- 
vious illness.  He  has  been  a  good  deal  in  the  Tropics,  the  last  time  a 
year  ago.  For  the  past  two  months  he  has  been  drinking  heavily 
and  has  gained  weight. 

Physical  examination  shows  that  the  apex  of  the  heart  extends 
I  cm.  outside  the  nipple  line,  the  right  border  4  cm.  from  midsternum. 
At  the  apex  is  a  soft  systolic  murmur,  heard  louder  as  one  approaches 
the  base  and  loudest  at  the  aortic  cartilage.  The  pulmonic  second 
sound  is  not  accentuated.  The  knee-jerks  are  not  obtained,  and  there 
is  brawny  edema  below  the  knees;   otherwise  physical  examination, 


EDEMA   OF   THE   LEGS  483 

including  the  blood  and  urine,  is  negative.  Systolic  blood-press- 
ure, 125.  No  temperature  in  ten  days'  observation,  during  which 
time  he  lost  5  pounds  and  got  rid  of  his  edema. 

Discussion. — The  patient  has  been  in  the  Tropics,  and  the  idea  of 
filariasis  comes  at  once  to  mind  as  soon  as  edema  of  the  legs  is  men- 
tioned. Filariasis,  however,  almost  invariably  affects  one  leg  by 
blocking  the  lymphatics  in  the  neighborhood  of  the  groin.  I  have 
seen  no  record  of  a  filarial  disease  aflfecting  both  legs. 

Beriberi  is  another  tropical  disease  causing  edema  and  having  no 
predilection  for  unilateral  distribution.  This  disease,  however,  is 
never  confined  to  the  legs,  though  its  manifestations  may  be  most 
marked  there.  The  absence  of  knee-jerks  is  compatible  with  beri- 
beri, but  also  with  the  diagnosis  next  to  be  mentioned. 

It  is  notable  that  his  excessive  alcoholism  began  shortly  before 
the  trouble  in  his  legs.  The  only  reason  for  any  doubt  regarding  the 
diagnosis  of  alcoholic  neuritis  in  this  case  is  the  condition  of  the 
heart,  which  appears  to  be  somewhat  enlarged,  although  the  ab- 
normality is  not  very  notable.  The  effects  of  alcoholism  upon  the 
heart  have  not,  in  my  opinion,  been  very  thoroughly  recorded.  In 
some  cases  we  seem  to  have  an  acute  and  ominous  weakening  of  the 
heart  during  or  after  an  alcoholic  debauch,  yet  without  any  permanent 
changes  in  the  organ.  Such,  at  any  rate,  is  the  most  natural  con- 
clusion from  the  rapidity  with  which  such  patients  pick  up  and  their 
steady  good  condition  thereafter,  provided  they  will  stop  drinking  and 
continue  their  abstinence.  In  the  present  state  of  our  knowledge  it  is 
impossible  to  determine  when  one  sees  a  bad  cardiac  dropsy  in  an 
alcoholic  whether  the  condition  will  result  in  a  permanently  weakened 
heart  or  whether  it  will  all  clear  up.  We  have  to  wait  until  the  effects 
of  the  alcoholism  have  worn  off.  After  that  quite  marvelous  improve- 
ments sometimes  occur. 

Outcome. — On  the  21st  of  July  he  seemed  to  be  well  and  left  the 
hospital. 

Case  206 

A  child  of  seven  entered  the  hospital  July  27th,  1910.  Four 
years  ago  the  boy  had  a  lump  appear  under  the  right  jaw;  after 
four  weeks  it  was  opened  and  discharged  profusely  and  in  two  weeks 
was  well.  Otherwise  he  has  been  perfectly  well  until  five  days  ago, 
when  small  tender  tumors  were  noticed  on  both  sides  of  his  neck. 
Two  days  ago  he  was  a  little  sleepy  in  the  daytime,  but  played  as 
usual.     Yesterday  he  complained  that  his  shoes  were  too  small  and 


484  DIFFERENTIAL   DIAGNOSIS 

his  ankles  were  found  to  be  swollen.  He  lay  about  the  house  and 
would  not  eat.  Last  night  he  seemed  feverish  and  breathed  very 
hard.     To-day,  for  the  first  time,  his  urine  appeared  red. 

On  physical  examination  the  heart's  apex  extended  i  cm.  outside 
the  nipple  line,  right  border  2  cm.  from  midsternum.  The  heart 
was  negative,  save  that  the  first  sound  was  somewhat  valvular  in  qual- 
ity and  the  strength  of  successive  beats  varied  a  good  deal.  The 
lungs  were  negative.  The  abdomen  showed  shifting  dulness  in  the 
flanks,  with  moderate  edema  of  the  legs.  Systolic  blood-pressure, 
125.  The  temperature  ranged  from  99°  to  100.5°  F.  during  first  week; 
after  that  normal.  The  urine  averaged  25  ounces  in  twenty-four 
hours,  was  always  smoky  in  color;  specific  gravity  averaged  1016. 
The  sediment  contained  much  free  blood  and  a  moderate  number  of 
blood-casts,  as  well  as  fine  and  coarse  granular  casts.  No  fat  was  seen 
upon  the  casts  in  fourteen  examinations.  At  entrance  the  white 
cells  numbered  25,500,  with  a  polynuclear  leukocytosis.  This  de- 
creased day  by  day,  and  was  normal  August  2d. 

Discussion. — Presumably,  a  tonsillitis  or  some  other  oral  infection 
has  preceded  the  glandular  suppuration  with  which  this  malady  was 
ushered  in.  When  any  such  infection  is  followed  by  edema  of  the 
legs,  we  should  at  once  call  to  mind  the  fact  that  even  a  very  trifling 
tonsillar  infection  may  be  followed  by  severe  nephritis.  All  the 
recent  milk  epidemics  of  streptococcic  sore  throats  have  shown  ex- 
amples of  this  type  of  nephritis.  The  ascites,  the  fever,  dyspnea, 
anorexia,  leukocytosis,  and  (for  a  child)  the  sHght  hypertension  lead 
us  to  take  the  condition  of  the  urine  very  seriously.  The  amount  of 
blood  in  it  would  probably  have  made  the  diagnosis  of  nephritis  in- 
evitable in  any  case. 

What  is  to  be  said  regarding  the  condition  of  the  heart?  It  seems 
to  me  more  than  possible  that  the  same  infection  which  has  damaged 
the  kidney  has  not  spared  the  heart.  How  great  the  damage  is  only 
time  can  show.  There  is  no  reason,  however,  to  believe  that  the 
edema  is  of  the  cardiac  type.  The  heart's  action  is  not  sufficiently 
disturbed. 

Outcome. — By  the  12th  of  August  the  albumin  had  disappeared 
and  the  sediment  was  at  that  time  negative.  The  edema  and  ascites 
had  gone  and  he  felt  well.     On  the  13th  he  went  home. 

Case  207 

A  signal  man  on  the  Boston  and  Maine,  thirty-nine  years  old, 
entered  the  hospital  December  8,  1910.     Four  days  ago  the  patient 


EDEMA   OF   THE   LEGS  485 

noticed  that  his  calves  were  swelling.  This  swelling  gradually  ex- 
tended to  include  the  ankles  and  feet  and  then  the  thighs,  and  was 
accompanied  by  constant  aching.  On  further  questioning,  he  remem- 
bers that  on  November  29th  he  took  a  3-mile  walk,  very  unusual  for 
him,  after  which  his  legs  trembled  and  felt  very  weak.  For  two  or 
three  weeks  he  noticed  dyspnea  on  exertion.  For  the  past  four  days 
he  has  had  an  unusually  good  appetite.  He  worked  until  last  night. 
He  has  been  steadily  gaining  weight.  There  is  nothing  of  interest  in 
his  family  history  or  in  his  past  history,  except  that  for  several  years 
he  has  noticed  palpitation  on  exertion  or  on  excitement.  He  has 
been  a  pretty  steady  drinker  for  sixteen  years,  and  occasionally  takes  a 
drink  of  whisky  before  breakfast.     He  smokes  constantly. 

Physical  examination  shows  good  nutrition,  pupils  sHghtly  irregu- 
lar, but  reacting  normally.  The  heart  is  negative  except  for  a  very 
soft  systolic  murmur  at  the  apex.  Abdomen  and  urine  negative. 
Reflexes  normal.     Much  soft  edema  of  the  legs  and  thighs. 

Discussion. — In  the  absence  of  any  cardiac  hypertrophy,  and  with 
a  systolic  blood-pressure  of  135,  such  as  is  present  in  this  case,  with 
normal  blood  and  urine,  it  is  difficult  to  explain  the  symptoms  of 
myocardiac  weakness.  There  is  no  evidence  of  any  infectious  disease 
and  no  signs  of  nephritis.  It  seems  to  me  that  we  must  attribute  the 
heart  weakness,  as  in  a  previous  case,  to  the  alcoholism.  Just  why 
this  trouble  should  have  fallen  upon  him  now  rather  than  sooner  I 
cannot  say.  Only  the  outcome  of  the  case,  carefully  followed  for 
months,  can  tell  us  whether  the  heart  is  permanently  crippled  or  only 
temporarily  poisoned.  It  is  one  of  the  standard  wonders,  revealed 
in  medical  practice,  what  an  alcohohc  can  throw  off  in  the  way  of 
cardiac,  renal,  cerebral,  and  other  manifestations,  provided  he  can 
once  decide  to  cut  out  alcohol. 

Outcome. — ^When  examined  December  nth  the  edema  had  left 
the  calves,  but  they  were  still  extremely  tender.  There  were  then 
rales  in  both  bases.  Wassermann  reaction  negative.  By  the  28th 
of  December  he  seemed  to  be  practically  well  and  left  the  hospital, 
having  lost  11  pounds  in  three  weeks,  owing  to  the  disappearance  of 
dropsy. 

Case  208 

A  cigar  maker  of  fifty-nine  entered  the  hospital  March  14,  191 2. 
The  patient's  only  complaint  at  the  present  time  is  of  swelling  of  the 
legs,  which  appeared  ten  days  ago.  He  admits  on  cross-questioning, 
however,  that  a  year  ago  he  was  in  the  Out-patient  Department  com- 


486 


DIFFERENTIAL  DIAGNOSIS 


plaining  of  sLx  weeks'  dull  steady  pain  across  the  upper  abdomen.  At 
that  time  he  was  jaundiced  and  had  morning  nausea,  but  he  soon 
recovered  from  all  these  symptoms  and  has  had  no  treatment  since. 
For  the  last  fifteen  years  he  has  passed  urine  two  or  three  times  at  night. 
He  now  feels  strong  and  works  as  usual,  has  a  good  appetite,  and  sleeps 
well.  He  has  no  headache,  nausea,  or  dyspnea.  He  takes  two  or  three 
whiskies  and  three  or  four  beers  a  day.     He  denies  venereal  disease. 

Physical  examination  showed  a  well-developed,  flabby  patient, 
making  jerky  or  poorly  co-ordinated  movements,  and  with  a  strong 
odor  of  alcohol  on  the  breath.  Pupils  and  reflexes  normal.  Heart's 
apex  extended  i|  cm.  outside  the  nipple  line.  Sounds  were  regular, 
good  quality,  no  murmurs.  Aortic  second  accentuated.  The  arte- 
rial walls  not  felt,  lungs  negative. 
Abdomen  showed  dull  tympany 
in  the  flanks,  but  no  shifting  with 
change  of  position.  The  edge  of 
the  liver  was  not  felt.  There 
was  marked  edema  of  the  legs 
and  thighs.  Dr.  F,  C.  Shattuck 
said,  ''Inferentially,  cardiac  in- 
sufficiency in  a  potator."  My 
own  diagnosis  was  arteriosclerosis, 
hypertrophied  and  dilated  heart, 
cirrhosis  of  the  liver,  question- 
able chronic  glomerular  nephri- 
tis. Stomach-tube  examination 
showed  that  the  stomach  was 
empty  before  breakfast,  was  not 
enlarged  or  displaced,  and  con- 
tained no  free  HCl  after  a  test- 
meal.  Wassermann  reaction  was 
suspicious  March  15th,  negative  March  19th.  Blood-pressure,  190 
mm.  Hg.  at  entrance,  systolic;  90  mm.  Hg.,  diastolic;  175  mm.  Hg. 
the  next  day  (Fig.  178). 

The  blood  was  not  remarkable.  The  urine  averaged  30  ounces 
in  twenty-four  hours;  specific  gravity  ranged  about  1014.  There  was 
an  occasional  granular  cast  and  a  little  free  blood  in  the  sediment. 
During  the  two  weeks  of  his  stay  in  the  hospital  the  edema  slightly 
increased,  and  there  was  constant  mental  dulness  or  confusion.  After 
the  26th  he  was  entirely  irrational  and  took  almost  no  food.  On  the 
30th  he  died. 


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EDEMA  OF  THE  LEGS  487 

Discussion. — Apparently,  the  first  symptom  was  nocturia.  This, 
as  is  well  known,  may  be  due  to  either  the  heart  or  the  kidney,  and, 
as  is  somewhat  less  well  known,  to  hepatic  cirrhosis.  The  year's 
history  of  jaundice,  morning  nausea,  and  steady  epigastric  pain  in  an 
alcohoHc  patient  points  strongly  toward  hepatic  cirrhosis.  The  main 
question  of  interest,  as  it  seems  to  me,  is,  what  else  has  he?  With 
so  high  a  blood-pressure  the  heart  is  almost  certainly  affected,  the 
kidney  very  possibly.  The  presence  of  free  blood  in  the  renal  system 
makes  the  latter  suspicion  more  probable.  We  have  no  reason  to 
believe  that  the  heart  valves  are  damaged.  Enlargement  and  dilata- 
tion are  the  probable  inferences.  At  his  age  this  condition  is  as 
likely  to  be  due  to  arteriosclerosis  as  to  kidney  trouble,  despite  the 
definite  evidences  in  the  urine. 

When  this  patient  first  entered,  we  felt  that  he  might  clear  up 
like  some  of  the  other  alcoholics  whose  history  has  been  given  in  pre- 
vious pages.     We  were  not  prepared  for  his  steady  decline. 

Outcome. — ^Autopsy  showed  cirrhosis  of  the  liver,  arteriosclerosis, 
hypertrophy,  and  dilatation  of  the  heart,  subacute  glomerular  nephri- 
tis with  arteriosclerotic  degeneration,  obsolete  tuberculosis  of  the 
left  apex. 

Case  209 

A  machinist  of  eighty  entered  the  hospital  March  30,  191 2. 
The  patient's  father  died  of  what  was  called  "tobacco  heart,"  his 
mother  of  shock,  one  brother  of  diabetes.  His  wife  died  of  shock. 
She  has  had  one  child,  who  is  Hving  and  well;  no  miscarriage.  The 
patient  lives  alone,  and  spends  his  time  working  on  an  invention  for 
"increasing  and  transmitting  power;  that  is,  for  making  five  pounds 
lift  six  pounds."  He  expects  soon  to  sell  the  machine  for  $15,000. 
For  the  present  he  is  spending  15  cents  a  day  for  food. 

For  the  past  three  weeks  he  has  noticed  swelHng  of  his  feet  and 
legs  and  says  that  he  has  lost  all  ambition.  He  has  no  dyspnea.  On 
the  contrary,  he  climbs  four  flights  of  stairs  a  day  without  resting  and 
without  losing  his  wind.  He  has  no  headache,  good  appetite  and 
digestion,  and  says  he  has  not  lost  weight  or  strength. 

Physical  examination  showed  poor  nutrition,  pallor,  and  dry 
skin.  Pupils  and  reflexes  normal.  Heart  and  urine  negative.  Arte- 
ries slightly  tortuous  and  beaded.  Blood-pressure,  155  mm.  Hg., 
systolic;  90  mm.  Hg.,  diastoHc.  Blood  and  urine  normal.  No  fever 
in  ten  days'  observation.  The  edema  disappeared  in  a  week,  during 
most  of  which  time  he  was  eating  or  sleeping.     At  the  end  of  that  time 


488  DIFFERENTIAL  DIAGNOSIS 

he  was  anxious  to  go  back  to  work,  and  was  allowed  to  go  home. 
Treatment  consisted  of  magnesium  sulphate,  i  ounce  in  concen- 
trated solution  before  breakfast,  for  two  days.  This,  with  an  occa- 
sional hypnotic  and  laxative,  was  all  that  was  given  him. 

Discussion. — At  this  patient's  age,  and  with  arteries  like  those 
described,  it  is  almost  inevitable  to  attribute  his  edema  to  arterio- 
sclerosis, even  though  he  has  shown  no  dyspnea  or  distinctively 
cardiac  symptom. 

At  this  age  an  edema  of  the  legs  is  a  much  more  serious  symptom 
than  in  a  younger  person.  With  the  absence  of  headache,  marked 
hypertension,  and  anemia  it  does  not  seem  possible  to  incriminate  the 
kidney.  There  is  nothing  pointing  to  cirrhosis.  Cardiac  weakness, 
therefore,  is  our  best  surmise. 

Outcome. — He  died  October  28,  1912,  at  Tewksbury  State  Hos- 
pital. Diagnosis:  Arteriosclerosis  and  acute  bacillary  dysentery. 
Two  months  earlier  he  had  seemed  quite  well. 

Case  210 

A  man  of  twenty- three,  in  a  cotton  mill,  entered  the  hospital 
April  13,  1912.  The  patient's  family  history  is  negative.  His  mother 
tells  him  that  when  he  was  a  year  old  his  face  was  so  swollen  for  two 
months  that  he  could  not  open  his  eyes.  Otherwise  his  past  history 
and  habits  are  good.  When  he  was  five  years  old,  his  right  leg,  below 
the  knee,  began  to  swell,  and  a  few  years  later  his  left.  This  swelling 
has  slowly  increased  ever  since  and  has  extended  into  the  thighs  and 
scrotum,  but  not  elsewhere.  Jt  is  always  less  when  he  Hes  down  and 
can  be  reduced  by  the  use  of  a  rubber  bandage.  There  is  no  pain  or 
other  discomfort.  At  intervals  of  from  three  to  five  months  (except 
during  the  last  two  years)  he  has  had  attacks,  substantially  as  follows: 
Severe  pain  and  tenderness  would  appear  in  both  groins,  soon  followed 
by  a  shaking  chill  and  the  vomiting  of  much  fluid,  then  by  a  fever  and 
somnolence.  He  has  not  hved  in  a  malarial  region,  so  far  as  he 
knows.  His  urine  has  never  been  milky,  but  he  passes  it  twice  or 
thrice  in  the  night.  The  swelling  of  his  legs  has  never  interfered 
seriously  with  his  work,  and  has  sometimes  been  a  source  of  income 
in  circus  shows. 

On  physical  examination  the  right  pupil  is  larger  than  the  left; 
otherwise  both  are  normal.  The  chest  and  abdomen  show  nothing 
of  interest.  The  condition  of  the  legs  is  shown  in  Figs.  179  and  180. 
The  skin  of  the  thighs  and  calves  was  much  thickened  and  covered 
in  places  with  crater-like  elevations,  some  old  and  white,  some  recent 


EDEMA   OF   THE   LEGS 


489 


and  red.  The  right  calf  is  88  cm.;  the  left,  68  cm.;  the  right  thigh, 
83  cm.;  the  left,  82  cm.  Blood  and  urine  were  normal.  No  fever 
in  two  weeks'  observation. 

By  the  use  of  silver  ointment  the  skin  became  soft  and  clean.     He 
was  kept  in  bed  with  the  legs  raised,  but  given  no  medicine.      During 


Fig.  179. — Condition  of  legs  in  Case  210 
at  entrance. 


Fig.  180. — Condition  of  legs  in  Case  210 
at  entrance. 


the  last  three  days  of  his  stay  in  the  medical  ward  he  voided  430 
ounces  of  urine  (Fig.  181),  with  marked  reduction  in  the  size  of  his 
legs. 

Discussion. — ^An  enlargement  which  has  existed  since  the  age  of 
five,  and  which  was  confined  for  some  years  to  one  leg,  has  evidently 


490 


DEFFERENTL4L  DIAGNOSIS 


the  local,  not  the  general,  t>pe  of  etiology.  The- statement  that  his 
urine  has  never  been  milky  and  that  he  has  never  lived  in  the  Tropics 
tends  to  rule  out  filarial  disease.  Blood  examination  is  also  quite 
negative. 

We  cannot  call  the  condition  hereditary,  since  he  was  free  from 
it  for  the  first  four  years  of  his  life.  What  was  the  cause  of  his  swollen 
face  when  he  was  a  year  old?  We  can  only  conjecture.  With  the 
exclusion  of  heredity,  trophedema,  and  filariasis,  we  have  nothing  but 
elephantiasis  left,  and  the  local  signs  support  this  diagnosis.^ 

Of  much  interest  was  the  prodigious  diuresis  which  we  were  able 
to  observe  when  we  got  him  at  rest  in  bed.     Clearly,  the  juice  was 


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(recorded  in  ounces). 


running  out  of  his  legs.  Edema  was,  therefore,  an  element  in  his 
condition.  Of  further  interest  is  the  result  of  operation  shown  in 
Figs.  182,  183. 

Outcome. — He  was  transferred  to  the  surgical  wards,  where  a  con- 
siderable amount  of  the  hypertrophied  tissue  was  removed.  The 
resulting  changes  are  shown  in  Figs.  182,  183.  The  thighs  after  opera- 
tion measured  22  inches;  the  calves,  17I  inches.     Examination  of  the 

^  "Three  Cases  of  Sporadic  Elephantiasis  of  the  Lymphatic  Type,"  by  George  C. 
Shattuck,  M.  D.,  Boston  Med.  and  Surg.  Jour.,  January  27,  iQio;  "Etiology  of  Ele- 
phantiasis," by  George  C.  Shattuck,  M.  D.,  Boston  Med.  and  Surg.  Jour.,  November 
10,  1910. 


EDEMA   OF   THE   LEGS 


491 


excised  tissue,  by  Dr.  W.  F.  Whitney,  showed  fibrous  tissue  filled 
with  lymph-spaces  containing  serum.  The  fibrils  were  more  or  less 
separated  by  serous  fluid.     The  patient  left  the  hospital  on  the  25th 


Fig.  182. — Condition  of  patient's  legs  after 
operation  (Case  210). 


Fig.  183. — Condition  of  patient's  legs  after 
operation  (Case  210). 


of  May,  191 2.  In  February,  1913,  the  patient  writes  that  he  is  feeling 
very  well,  and  that  the  elastic  stockings  which  he  is  now  wearing  pre- 
vent any  recurrence  of  the  enlargement  at  the  site  of  operation. 

Case  211 

A  draughtsman  of  sixty-five  entered  the  hospital  May  11,  191 2. 
The  patient's  wife  died  of  tuberculosis  thirty  years  ago.  His  family 
history  is  good.  He  has  two  children  living  and  well.  He  remembers 
no  previous  illness,  and  says  he  has  been  well  and  strong.  He  has 
taken  no  tobacco  or  alcohol  and  denies  venereal  disease.     He  has  been 


492 


DIFFERENTIAL  DIAGNOSIS 


accustomed  to  work  twelve  to  eighteen  hours  a  day,  and  has  taken  long 
bicycle  rides  on  Sundays.  He  entered  the  hospital  with  a  diagnosis 
of  "chronic,  nephritis  and  chronic  bronchitis,"  made  by  his  family 
physician. 

For  three  months  he  has  been  running  down,  losing  weight, 
strength,  and  ambition.  For  two  months  he  has  had  moderate 
swelhng  of  the  feet  and  a  persistent  dry  cough.  His  appetite  is 
poor,  his  digestion  good.  He  has  had  no  headache,  no  nausea,  no 
dyspnea  or  nocturia.  He  sleeps  well.  Cramps  in  his  hands  and 
feet  he  has  noticed  for  three  or  four  years.  He  finished  his  contract 
as  a  draughtsman  this  morning,  then  immediately  gave  up  and  came 
to  the  hospital.  Two  months  ago  he  weighed  136  pounds,  with  his 
clothes;  at  entrance  he  weighed  108  pounds,  without  clothes. 

Physical  examination  showed  obvious 
emaciation,  but  nothing  abnormal  was  de- 
tected in  the  chest  or  abdomen  except 
spasm  and  dulness  in  the  right  hypo- 
chondrium.  The  urine  averaged  35  ounces 
in  twenty-four  hours;  specific  gravity, 
1020;  very  slight  trace  of  albumin  and  a 
few  granular  casts.  Blood  normal.  Blood- 
pressure,  125  mm.  Hg.,  systolic;  75  mm. 
Hg.,  diastolic.  My  diagnosis  was  arterio- 
sclerosis, myocardial  weakness,  vascular 
crises  in  the  peripheral  arteries.  The 
course  of  the  temperature  is  shown  in  Fig. 
184.  Wassermann  reaction  negative.  He 
coughed  up  a  good  deal  of  mucopurulent 
sputum  which  contained  no  tubercle  bacilli. 
His  edema  rapidly  cleared  up,  his  heart 
seemed  to  be  well  compensated,  and  his 
chief  trouble  seemed  to  be  malnutrition.  He  slept  most  of  his  time 
and  took  food  poorly.  On  the  17th  rales  were  noted  throughout 
both  lungs,  especially  in  the  middle  of  the  left  back,  where  they  were 
coarse  and  loud.  At  the  same  time  he  became  incontinent  of  urine 
and  feces.  He  was  considered  to  have  a  terminal  bronchopneu- 
monia. 

Discussion. — It  seems  to  me  altogether  pathetic  that  a  man  of  his 
age,  with  such  obviously  serious  illness,  should  have  worked  up 
to  the  very  day  that  he  entered  the  hospital.  His  history  is  of  three 
months'  weakness,  with  two  months  of  cough  and  edema  of  the 


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EDEMA   OF   THE   LEGS  493 

feet,  and  the  loss  of  20  pounds  in  this  time.  The  cause  of  his  edema 
and  fever  we  were  altogether  unable  to  determine.  We  supposed 
his  cough  to  be  of  nervous  origin,  though  possibly  due  to  cardiac 
weakness.  There  was  nothing  of  any  special  significance  in  the  lungs 
until  the  day  before  his  death,  and  the  conditions  then  found  were 
taken  as  terminal  rather  than  etiologic. 

The  case  illustrates  a  total  failure  of  our  diagnostic  resources. 

Outcome. — He  died  on  the  i8th.  Autopsy  showed  chronic  tuber- 
culosis of  both  lungs,  general  mihary  tuberculosis,  tuberculous  peri- 
tonitis, tuberculosis  of  the  ileum,  slight  arteriosclerotic  degeneration 
of  the  kidneys. 

Remarks. — In  looking  back  upon  the  case  in  the  Hght  of  the  autopsy 
I  do  not  see  how  we  could  have  done  much  better.  The  edema  was 
doubtless  due  to  an  infectious  myocarditis  with  weakening  of  the 
heart's  action. 

Case  212 

A  shoemaker  of  eighteen,  born  in  Turkey,  entered  the  hospital 
June  22,  191 2.  He  quit  work  two  weeks  ago  because  of  swelling  of  his 
feet,  headache,  and  nosebleed.  He  has  never  been  sick  before  and  has 
excellent  habits.  During  the  two  weeks  that  have  passed  the  swelling 
has  extended  up  the  legs  and  thighs,  but  has  never  been  noticed  in 
the  face.  Appetite  and  digestion  are  excellent,  eyesight  good,  no 
dyspnea  or  nocturia. 

Physical  examination  shows  a  respiration  suggesting  Cheyne- 
Stokes.  The  heart's  impulse  seen  and  felt  in  the  fourth  space,  |  cm. 
outside  the  nipple  line.  No  enlargement  on  the  right.  Pulmonic 
second  greater  than  the  aortic  second.  Apex  second  sound  ringing. 
Radials  and  brachialis  slightly  roughened.  The  course  of  the  blood- 
pressure  is  shown  in  Fig,  185.  The  urine  averaged  25  ounces  in 
twenty-four  hours  for  the  first  week,  with  a  very  slight  trace  of  al- 
bumin and  a  moderate  number  of  hyaline  casts,  some  with  a  few 
cells  adherent,  many  red  corpuscles.  Blood  negative.  Wassermarm 
reaction  negative.  After  two  days  in  the  ward,  with  a  nephritic  diet, 
and  I  ounce  of  concentrated  solution  of  magnesium  sulphate  every 
morning,  the  edema  was  gone.  A  week  after  entrance  the  urine  rose 
to  70  ounces  and  the  patient  felt  perfectly  well.  At  times  there  was 
a  suggestion  of  presystoUc  thrill  and  roll  at  the  apex. 

Discussion. — Edema  of  the  legs  in  a  man  of  eighteen,  associated 
with  headache  and  nosebleed,  and  later  with  Cheyne-Stokes'  breath- 
ing and  hypertension,  compels  us  to  make  the  diagnosis  of  nephritis, 


494 


DIFFERENTIAL  DIAGNOSIS 


whatever  the  urine  shows.  As  a  matter  of  fact,  the  urine  would 
probably  have  inchned  us  strongly  toward  such  a  diagnosis  even  had 
the  other  s}Tnptoms  been  less  clear. 

The  point  of  interest  is  to  determine  whether  this  is  an  acute 
nephritis,  as  the  history  suggests,  or  an  exacerbation  of  a  chronic 
process.  At  the  time  of  entrance  the  blood-pressure  of  215  mm.  Hg. 
made  me  feel  confident  that  we  were  deahng  with  a  chronic  case, 
and  even  when  the  pressure  had  dechned  so  wonderfully  (Fig.  185) 
I  still  felt  that  the  case  must  be  a  chronic  one. 


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Case  212.     Note  the  diuresis  as  blood-pressure  falls. 


Outcome. — The  patient  left  the  hospital  July  ist.  March  19, 
1913,  the  patient's  physician  writes  that  he  is  feehng  perfectly  well 
and  working  daily.  The  doctor  has  recently  examined  his  urine  and 
finds  it  entirely  normal. 

Remarks. — In  view  of  this  outcome,  it  seems  to  me  clear  that  I  was 
wrong  in  calling  the  case  chronic  rather  than  acute  nephritis.  If  so, 
it  is  a  matter  of  some  importance  as  proving  that  even  a  temporary 
and  curable  disease  of  the  kidney  may  produce  so  marked  a  hyper- 
tension. 


CHAPTER  XI 

FREQUENT  MICTURITION  AND  POLYURIA 

Polyuria,  or  an  abnormally  large  daily  excretion  of  urine,  is,  of 
course,  quite  different  from  frequency  of  urination.  Nevertheless, 
they  are  so  often  associated  in  cases  of  disease  that  it  is  convenient 
to  consider  them  in  the  same  chapter. 

Persons  vary  a  good  deal  in  perfect  health  in  the  number  of  times 
that  they  pass  urine  during  twenty-four  hours.  The  great  majority 
of  healthy  persons  do  not  have  to  rise  during  the  night  to  pass  urine, 
but  in  a  small  majority  this  is  habitual  and  does  not  seem  to  depend 
upon  any  unusual  amount  of  water  ingested  during  the  evening.  Of 
course,  it  is  obvious  and  familiar  that  anyone  who  takes  a  large  amount 
of  liquid,  especially  of  beer,  during  the  evening,  is  Ukely  to  have  to 
pass  urine  during  the  night;  but  aside  from  this  cause,  and  from  the 
rare  cases  of  habitual  nocturia,  there  are  a  good  many  people  who 
suffer  from  nocturia  whenever  they  are  "nervous."  Sometimes  it 
appears  as  if  both  the  nervousness  and  the  increased  frequency  of  mic- 
turition had  a  common  cause  in  the  nervous  and  vascular  ataxia. 
If  this  is  so,  we  cannot  truly  say  that  the  nervousness  is  the  cause  of 
the  urinary  trouble,  but  is  rather  a  concomitant  effect  of  a  deeper 
cause,  perhaps  low  peripheral  pressure  and  splanchnic  congestion. 

Aside  from  these  temporary  causes,  any  of  which  may,  of  course, 
act  during  the  day  as  well  as  during  the  night,  the  commonest  t5^e 
of  urinary  frequency  is  that  associated  with  prostatic  enlargement, 
whether  simple  or  carcinomatous.  In  elderly  men  this  is  by  far  the 
commonest  cause  of  frequency. 

In  women  the  pressure  of  uterine  or  ovarian  tumor's  and  the 
irritation  of  pelvic  exudates  blend  their  effects  with  psychic  influ- 
ences in  a  way  that  makes  it  dif&cult  to  distinguish  the  two.  Either 
or  both  sets  of  causes  affect  women  all  the  more  strongly  because  of 
the  shortness  of  the  female  urethra. 

Bladder  irritation,  whether  from  definite  cystitis  or  from  the 
presence  of  urine  sent  down  from  a  tuberculous  kidney,  is  perhaps 
the  next  most  frequent  cause  of  urinary  frequency.  Cystitis,  of  course, 
is  also  an  accompaniment  of  many  prostatic  enlargements  in  men. 

405 


496  DIFFERENTIAL  DIAGNOSIS 

In  children  the  irritation  due  to  h^-peracid  urine,  to  balanitis, 
or  to  phimosis  may  be  sufficient  to  produce  frequency  or  even  in- 
continence. 

Among  the  rarer  causes  of  frequency  are  stone  in  the  bladder, 
cancer  of  the  bladder,  bilharzia  disease,  and  appendicitis.  All  of  these 
act,  of  course,  through  the  local  irritation  of  the  disease  present. 

In  diabetes  and  contracted  kidney  frequent  micturition  is  the 
result  of  a  large  amount  of  urine  which  has  to  be  discharged.  It  is 
noticed  most  at  night. 

Pregnancy  is  a  common  cause  for  urinary  frequency. 

Just  why  the  local  affections  of  the  kidney  and  renal  pelvis  (nephro- 
lithiasis, pyelitis,  pyelonephritis,  renal  tumor)  produce  urinary  fre- 
quency I  do  not  clearly  understand.  To  call  the  frequency  reflex 
is  merely  to  cover  up  our  ignorance.  Perhaps  the  urine  itself  is  espe- 
cially irritating  to  the  bladder  wall.     But  why? 

Case  213 

A  butler  of  forty-three  entered  the  hospital  December  21,  1911. 
His  family  history  was  not  important  save  that  one  sister  had  phthisis. 
He  has  had  no  serious  illness  in  the  past,  but  has  been  troubled  with 
constipation,  poor  appetite,  and  sleeplessness.  He  has  used  consider- 
able alcohol  up  to  six  months  ago,  but  none  since.  He  denies  venereal 
disease,  but  has  taken  potassium  iodid  and  mercury  for  two  or  three 
years.  There  has  been  pain  of  five  years'  duration  in  the  abdomen  and 
over  the  symphysis  every  month  or  less,  accompanied  by  constipation. 
Diagnoses  of  constipation,  then  of  lead-poisoning,  and  later  of  chronic 
appendicitis  have  been  made.  About  one  and  a  half  years  ago  a  lump 
appeared  on  the  scalp,  was  not  painful,  but  broke,  discharging  yellow 
serum  (?).  A  few  months  later  another  appeared  and  also  broke. 
Both  healed  very  slowly  after  discharging  a  couple  of  months. 

Eight  weeks  ago,  after  a  movement  of  bowels,  he  urinated;  at  end 
of  urination  gas  came  out  of  the  penis.  Since  then  he  has  had  burn- 
ing and  painful  micturition,  frequency  and  cloudy  urine,  at  times  very 
foul  and  of  a  peculiar  muddy  color.  There  has  been  considerable 
loss  of  weight  di^ring  the  past  two  months  (20  pounds  ?).  Frequency 
is  not  so  marked  of  late,  but  he  continues  to  pass  gas,  which  is  pre- 
ceded by  a  peculiar  pain.  There  has  been  no  cough,  dyspnea,  or  night- 
sweats,  but  he  has  had  an  occasional  chill.  He  has  taken  some 
morphin,  but  not  recently.  He  has  never  noticed  blood  in  the  urine, 
but  there  has  always  been  a  thick  sediment.  At  times  he  has  had  pain 
in  the  left  sacro-iliac  region. 


Frequent  Micturition 


NEUROTIC  STATES  (ACUTE  OR  CHRONIC)  ~|   cases  too  many  and  too  vaguely 

[       ENUMERABLE    FOR    GRAPHIC    REPRE- 

PREGNANCY  i      sentation. 

GONORRHEAL  URETHRITIS         IHI^B^^H^^HHHiil^HHi^^BH  2378 

CYSTITIS  (UNKNOWN  CAUSE)    ■^^^^^^^^^^^■■■1  1050 

CHRONIC    NEPHRITIS                               m^^^H^g^gmgi^^ggil  ^QQg 

PROSTATIC  OBSTRUCTION        i^^^HHBHIHIH  749 

STONE  IN    BLADDER                        ■■■^■l^^^H  729 

DIABETES  MELLITUS                      ■^■^■■11^  647 

UTERINE  FIBROMYOMA                W^^^^aM  539 

OVARIAN  CYSTOMA                        H^^^H  423 

a       be 

URINARY  TUBERCULOSIS'           1          I    T1  367 

MALIGNANT   NEOPLASM    OF"!     ^^ 

BLADDER                                       J     ^^  ^^^ 

STONE  IN   KIDNEY                          IH  150 

PAPILLOMA  OF  BLADDER             ■  55 

^Urinary  tuberculosis — i.  e., 

(a)  Tuberculosis  of  the  kidney 248 

(b)  Tuberculosis  of  the  bladder 94 

(c)  Tuberculosis  of  the  kidney  and  bladder 25 


Vol.  11—32  497 


498  DIFFERENTIAL   DIAGNOSIS 

On  examination,  he  is  rather  thin  and  pale;  ears  waxy.  The 
right  pupil  is  larger  than  the  left  and  both  react  normally.  There  are 
two  scars  of  abscesses  in  the  scalp.  The  throat  is  red;  breath  foul. 
There  are  no  glands  and  the  heart  is  negative.  In  the  lungs  the  right 
apex  is  duller  than  the  left,  with  breath  sounds  exaggerated,  fremitus 
increased,  and  an  occasional  musical  rale.  The  abdomen  is  negative 
save  for  a  burn-scar.     The  genitals  are  normal;  knee-jerks  present. 

The  patient  passed  4  ounces  of  cloudy  urme,  the  last  ounce  of 
which  was  thick,  white,  and  caused  some  burning.  There  was  no 
blood  seen,  no  "gas."  Temperature,  99.6°  F.;  pulse,  108;  respiration, 
32.  The  white  cells  were  8600.  The  urine  was  normal,  acid;  specihc 
gravity,  1012;  albumin,  slightest  possible  trace,  no  sugar.  The  sedi- 
ment contained  leukocytes,  bacteria,  a  few  red  corpuscles,  and  many 
pus  clumps.  Wassennann  reaction  was  slightly  positive.  Cystos- 
copy was  done  and  the  bladder  washed  clean.  In  upper  left  quadrant 
was  what  appears  to  be  the  opening  of  a  sinus  from  which  a  plug  of 
pus  protruded.     No  discharge  of  pus  seen. 

0.6  gm.  of  "606"  was  given;  considerable  discomfort  and  vomiting 
followed.  During  the  next  three  weeks  the  patient  showed  little 
change,  and  was  given  a  second  dose  of  "606,"  with  some  dis- 
comfort. A  second  cystoscopy  shows  the  same  ulcer  previously  seen, 
from  which  a  ribbon  of  pus  can  be  squeezed  out  by  pressure  on  left 
lower  quadrant  of  abdomen.  The  specific  gravity  of  the  urine  at  this 
time  is  1012,  with  a  shght  trace  of  albumin,  much  pus,  and  red  cells. 
No  fecal  matter  can  be  found. 

Discussion. — Pneumaturia,  or  the  passage  of  gas  with  the  urine, 
may  be  due  to  infection  of  the  urinary  tract  by  bacilli-producing  gas 
or  to  a  communication  between  the  bladder  and  the  intestinal  canal. 
Among  the  micro-organisms  which  produce  gas  in  the  urine  the  com- 
monest are  the  yeasts,  which  in  diabetes  often  fill  the  urine  with  air- 
bubbles.  Apparently  the  colon  bacillus  is  also  capable  of  splitting 
up  sugar  in  the  urine  so  as  to  produce  pneumaturia.  In  the  present 
case  the  extreme  foulness  of  the  urine  and  its  peculiar  muddy  color 
suggest*  a  communication  between  the  bladder  and  the  rectum. 

Some  features  in  the  case  suggest  syphiHs,  notably  the  lumps 
upon  the  scalp,  the  history  of  antis^'philitic  treatment,  and  the  Was- 
sermann  reaction.  If  the  patient  is  syphilitic,  it  may  well  be  that  a 
gummatous  process  of  the  lower  bowel  has  perforated  the  bladder,  so 
that  the  intestinal  contents  are  discharged  with  the  urine. 

Another  possibihty  is  of  a  diverticuhtis  connecting  with  the 
bladder. 


FREQUENT   MICTURITION   AND   POLYURIA  499 

The  results  of  cystoscopy  leave  little  doubt  that  such  a  com- 
munication exists. 

Outcome. — On  the  i8th  of  January  the  abdomen  was  opened 
and  a  mass  the  size  of  the  fist  was  found,  involving  the  sigmoid  flexure 
and  its  appendices.  There  was  also  an  abscess  near  the  rectum. 
After  the  drainage  of  this  abscess  the  patient  improved,  had  normal 
bowel  movements,  together  with  a  profuse  foul  purulent  discharge 
from  the  wound.  Rectal  examination,  February  8th,  showed  con- 
siderable thickening  and  moderate  tenderness,  but  no  fluctuation  high 
up  upon  the  left.  The  temperature  was  from  one  to  two  degrees 
above  normal. 

The  urine  was  now  pale,  cloudy,  looS  in  specific  gravity,  free  from 
albumin  and  sugar,  free  from  gas,  and  showing  nothing  of  importance 
in  the  sediment.  On  the  morning  of  June  20th  the  patient  com- 
plained of  shortness  of  breath,  became  excited,  and  rather  hysterical. 
The  temperature  was  then  99°  F.;  pulse,  no;  respiration,  20.  During 
the  afternoon  the  pulse  was  of  poor  quality,  heart  sounds  regular  but 
weak,  and  there  was  distention  and  pain  in  the  abdomen.  Next  day 
he  died,  rather  suddenly.  The  autopsy  showed  a  retroperitoneal 
pelvic  abscess,  presumably  arising  from  diverticulitis  of  the  intestine. 
The  lesion  upon  the  scalp  was  regarded  as  probably  a  gumma. 

Case  214 

A  tailoress  of  thirty-eight,  born  in  Russia,  entered  the  hospital 
June  24,  1908.  The  patient's  mother  died  of  cancer  of  the  stomach 
at  sixty- three;  otherwise  her  family  history  is  excellent.  She  had 
typhoid  fever  fifteen  years  ago.  Four  years  ago  she  had  an  illness  of 
six  months'  duration  similar  to  the  present. 

For  three  months  her  urine  has  been  thick  and  red  and  for  eight 
days  bloody,  and  passed,  as  she  says,  about  forty  times  a  day,  with 
great  pain.     She  has  no  other  S3anptoms. 

Physical  examination  was  negative,  save  for  a  slight  systoHc 
murmur  at  the  apex  of  the  heart  and  tenderness  over  the  pubes. 
The  urine  showed  considerable  sediment  of  pus  and  blood,  otherwise 
nothing  abnormal.  The  blood  was  negative.  There  was  no  fever 
in  two  weeks'  observation.  A  catheter  specimen  of  urine,  drawn  under 
aseptic  precautions,  showed,  on  bacteriologic  examination,  atypical 
streptococci.  It  was  then  injected  into  a  guinea-pig,  July  ist.  Au- 
gust 29th,  autopsy  of  this  animal  showed  nothing. 

Cystoscopy,  June  25th,  by  Dr.  Fred  T.  Murphy,  showed  no  stone 
and  nothing  abnormal  about  the  ureters.     The  base  of  the  bladder  was 


500  DIFFERENTIAL   DIAGNOSIS 

generally  injected.  The  patient  showed  no  reaction  after  the  injec- 
tion of  lo  mg.  of  old  tuberculin.  A  vaccine  was  made  from  the 
streptococci  isolated  from  the  urine  and  administered. 

Discussion. — The  history  of  typhoid  fever  fifteen  years  ago  brings 
to  our  mind  the  possibility  of  typhoid  cystitis,  since  we  know  that 
typhoid  fever  is  prone  to  settle  down  into  the  bladder  after  the  patient 
is  otherwise  well. 

But  this  is  apparently  an  acute  cystitis,  lasting  only  three  months 
and  beginning  suddenly.  It  is  hard  to  connect  such  an  illness  with 
the  typhoid  fever  of  fifteen  years  ago.  The  whole  question  is  as  to  the 
nature  of  the  cystitis.  We  have  no  reason  to  believe  that  it  is  due  to 
any  disease  either  above  or  below  the  bladder,  although  in  the  vast 
majority  of  cases  cystitis  is  to  be  thus  explained  and  is  not  an  inde- 
pendent entity.  The  fact  that  streptococci  are  the  only  organisms  dis- 
coverable does  not  in  any  way  prove  that  the  lesion  is  not  tuberculous, 
for  tubercle  bacilli  may  easily  be  overgrown  by  organisms  of  more 
rapid  development.  Much  more  important  is  the  negative  result  of 
animal  inoculation,  which  may  be  taken  as  practically  excluding 
tuberculosis. 

The  cause  of  cystitis  remains  somewhat  of  a  mystery.  The  time 
at  which  the  disease  originated  is  the  time  when  streptococcic  in- 
fections, especially  those  showing  themselves  in  the  throat,  are  most 
common.  Is  it  not  possible  that  a  streptococcic  infection  was  arrested 
in  its  way  out  of  the  body  and  took  root  in  the  bladder? 

Outcome. — By  the  5th  of  July  she  was  much  better,  and  was 
allowed  to  continue  her  treatment  in  the  Out-patient  Department. 
July  18,  1908,  she  reported  that  she  was  still  urinating  every  half- 
hour.     The  urine  was  normal. 

December  26,  1908,  the  patient  was  complaining  chiefly  of  pre- 
cordial distress  with  occasional  dyspnea.  The  heart  and  abdomen 
showed  nothing  abnormal.     She  was  evidently  worrying  a  good  deal. 

As  the  urine  continued  to  contain  streptococci,  on  May  11,  1909, 
cystoscopy  was  advised,  but  refused.  A  guinea-pig  test,  made  with 
the  sediment  of  the  urine,  showed  no  evidence  of  tuberculosis. 

June  24, 1 9 10,  she  reported  that  she  was  passing  water  every  fifteen 
minutes.  The  urine  at  that  time  contained  considerable  pus.  She 
was  given  an  injection  of  10  per  cent,  argyrol,  and  a  week  later  the 
urine  was  considerably  improved. 

February  21st  the  urine  was  in  all  respects  normal,  except  that 
the  specific  gravity  was  1006. 

July  12,  191 1,  she  reported  that  she  no  longer  was  troubled  about 


FREQUENT  MICTURITION  AND   POLYURIA  50I 

her  urine.     She  came  then  for  pain  in  the  back,  thought  to  be  due 
to  a  strain  from  faUing  down  stairs. 

December  i6,  1913,  she  came  to  the  hospital  for  coldness  and  pain 
in  the  little  and  ring  fingers  of  the  left  hand.  Hydrotherapy  was 
advised  and  produced  much  improvement. 

Case  215 

A  housekeeper  of  thirty-four  entered  the  hospital  August  5,  1908. 
The  patient's  mother  died  of  cancer;  one  brother  of  "blood-poisoning"; 
her  father  of  "asthma";  one  brother  in  infancy.  Another  brother  was 
murdered.  The  patient  had  rheumatic  fever  twelve  years  ago  and 
typhoid  fever  ten  years  ago.  She  has  taken  a  good  deal  of  wine,  ale, 
and  brandy. 

As  long  as  she  can  remember  she  has  been  troubled  with  frequent 
and  somewhat  painful  micturition.  At  the  time  of  menstruation  this 
trouble  is  increased  and  is  associated  with  headache  and  backache. 
For  the  past  two  years  her  symptoms  have  been  much  worse,  and  the 
desire  to  pass  urine  is  almost  constant,  though,  in  fact,  she  passes  it 
about  seven  times  during  the  day  and  not  at  all  at  night.  She  has 
worn  a  pessary  without  rehef .  Her  urine  has  been  normal  in  appear- 
ance. She  has  been  able  to  do  no  work  in  the  past  two  years  on 
account  of  backache. 

On  physical  examination,  the  patient  was  well  nourished  and 
showed  no  abnormalities  except  a  blowing,  systolic  murmur  at  the 
base  of  the  heart  and  an  antiflexed  uterus.  The  urine  was  normal. 
The  blood  showed  hemoglobin,  65  per  cent.;  red  cells,  4,860,000; 
white  cells,  5700.  The  stained  smear  showed  achromia,  but  was 
otherwise  negative.     While  in  bed  she  had  no  trouble  with  frequency. 

Discussion. — The  rheumatism  of  twelve  years  ago,  the  t}^hoid 
fever  two  years  after  that,  and  the  alcohoHc  history  are  probably 
of  no  special  significance  in  this  case.  A  point  of  great  importance 
is  the  presence  of  frequency  only  in  the  daytime  and  worse  at  the  time 
of  the  menstrual  period.  This  would  seem  to  connect  the  s}T3iptom 
with  the  pelvic  organs,  and  the  fact  that  the  urine  looks  normal 
strengthens  the  plausibiUty  of  this  theory.  Any  t}^c  of  cystitis  is 
Hkely  not  merely  to  produce  abnormahties  in  the  urine  w^hich  the 
patient  herself  notices,  but  to  distress  her  as  much  at  night  as  in  the 
daytime. 

The  idea  of  those  who  saw  this  patient  in  the  hospital  was  that 
local  irritation  from  the  anteflexed  and  deformed  uterus  was  the 
cause  of  this  patient's  frequency,  but  I  think  the  conclusion  may  be 


502  DIFFERENTIAL  DIAGNOSIS 

doubted.  One  sees  so  large  a  number  of  people  who  have  exactly 
the  same  pelvic  condition  without  any  frequency  at  all  that  I  am 
inclined  to  beheve  that  another  factor  is  the  important  one — the 
factor,  namely,  of  individual  h}'persensitiveness,  which  would  prob- 
ably have  resulted  in  frequency  even  had  the  uterus  been  wholly 
normal.  The  common  tradition  which  attributes  urinary  frequency 
to  anteflexion  of  the  uterus  rests,  I  think,  upon  insecure  foundation, 
for  the  reason  suggested  in  the  last  sentence. 

I  believe  that  the  patient's  anemia  and  general  debility,  as  shown 
in  her  headaches  and  backaches,  have  rendered  her  oversensitive  on 
the  physical  side,  and  are  the  chief  factors  in  accounting  for  her 
frequent  micturition. 

Outcome. — An  examination  under  ether,  August  14th,  showed  that 
the  uterus  was  drawn  to  the  right  by  what  seemed  to  be  a  tubo- 
ovarian  mass.  Operation  showed  a  fibroid,  the  size  of  a  hen's  egg,  on 
the  right  side  of  the  uterus,  near  the  fundus,  and  another  posteriorly. 
These  were  both  shelled  out  and  removed;  a  ventrosuspension  was 
done.  The  patient  convalesced  normally  and  left  the  hospital  on  the 
2d  of  September,  1908.  September  17,  1909,  she  reported,  in  answer 
to  a  letter,  that  she  was  still  troubled  by  pain  at  the  time  of  urination. 
No  cause  for  this  pain  was  found.  I  believe  it  due  to  a  nervous  hyper- 
sensitiveness. 

Case  216 

A  housewife  of  thirty-four,  born  in  Austria,  entered  the  hospital 
April  12,  1909.  For  the  past  four  months  she  has  passed  urine  very 
frequently,  sometimes  as  often  as  every  half-hour,  with  pain  and  burn- 
ing after  it.  Sometimes  the  urine  looks  normal,  sometimes  like  coffee. 
Three  weeks  ago  she  gave  birth  to  a  child,  and  for  a  week  after  that 
time  her  symptoms  were  relieved,  then  they  recurred,  and  were  as 
severe  as  before.  Two  years  ago  she  weighed  1 20  pounds,  with  clothes; 
now,  785  pounds,  without  clothes.  She  has  no  appetite  and  occa- 
sionally vomits.  She  remembers  no  previous  illness  and  has  had 
five  living  children. 

Her  mother  died  of  "a  cold";  otherwise  the  family  history  is  good. 
The  patient  was  poorly  nourished  and  pale.  The  chest  was  negative. 
In  the  left  upper  quadrant  of  the  abdomen  was  a  rounded  mass,  the 
size  of  an  orange,  transmitting  an  impulse  to  the  flank  and  back  when 
grasped  bimanually  (Fig.  186),  descending  slightly  with  respiration; 
shghtly  tender.  After  inflation  of  the  colon,  tympany  appeared  over 
the  mass.     There  was  tenderness  in  the  left  costovertebral  triangle, 


FREQUENT   MICTURITION  AND    POLYURIA 


503 


none  in  the  right.  There  was  sHght  edema  of  the  ankles.  Physical 
examination  was  otherwise  negative.  The  ?jlood  was  normal.  The 
urine  averaged  20  ounces  in  twenty-four  hours;  specific  gravity,  1026; 
albumin,  a  trace;  sediment,  much  pus,  a  few  red  corpuscles,  no  casts. 
The  patient  had  no  fever  above  99.5°  F.  during  her  week's  stay  in 
the  medical  wards.  The  temperature  always  fell  to  normal  in  the 
morning. 

Cystoscopy,  by  Dr.  Lincoln  Davis,  showed  a  sluggish  stream  of 
thick  pus  issuing  from  the  left  ureter.  Indigocarmin  was  excreted 
normally  from  the  right  ureter  and  none  at  all  from  the  left.  The 
bladder  was  somewhat  inflamed  and  sensitive,  but  showed  no  ulceration. 


Fig.  1S6. — ^Mass  felt  in  Case  216. 


Discussion. — When  the  urine  is  said  to  look  hke  coffee  we  must 
remember  that  the  presence  of  precipitated  urates  or  phosphates  is 
the  commonest  cause  of  such  an  appearance,  and  renders  it,  in  the 
great  majority  of  cases,  medically  insignificant.  Provided,  however, 
that  the  urinary  turbidity  is  due  to  pus  and  micro-organisms,  there 
is  something  in  the  intermittence  of  its  turbidity  which  suggests  pus 
of  renal  origin.  When  pus  comes  from  the  kidney  rather  than  the 
bladder  it  is  discharged  intermittently  into  the  urine,  so  that  some 
specimens  are  clear  and  others  turbid.  In  cystitis,  on  the  other  hand, 
every  specimen  is  turbid. 


504  DIFFERENTIAL  DIAGNOSIS 

The  emaciation,  the  family  history,  the  mass  in  the  region  of  the 
left  kidney,  and  the  abnormal  urine  shown  on  examination  to  con- 
tain pus,  make  it  clear,  even  in  advance  of  cystoscopy,  that  we  are 
dealing  with  a  purulent  affection  of  the  kidney,  that  is,  either  with 
pyonephrosis,  pyelonephritis,  or  tuberculous  kidney.  The  absence 
of  ulceration  in  the  bladder  favors  a  non-tuberculous  renal  lesion. 

Outcome. — Operation,  April  21st,  showed  a  kidney  increased  in 
size  transformed  into  a  sacculated  tumor,  15  cm.  in  diameter  and  filled 
with  pus.  The  ureter  was  much  thickened.  No  definite  evidence  of 
tuberculosis  was  found.  The  kidney  and  7  cm.  of  ureter  were  removed 
without  difficulty.  The  patient  made  an  excellent  recovery  and  left 
the  hospital  May  24th,  apparently  well. 

Case  217 

A  housewife  of  forty-nine  entered  the  hospital  December  11,  191 1. 
The  patient's  mother  died  of  cancer  in  the  neck;  otherwise  her  family 
history  is  good. 

Thirteen  years  ago  she  began  to  have  marked  frequency  of  urina- 
tion, passing  water  every  fifteen  minutes  in  order  to  relieve  her  pain 
in  the  region  of  the  bladder.  At  times  the  stream  was  checked  sud- 
denly, causing  great  pain.  Twelve  years  ago  she  was  in  the  Massa- 
chusetts Homeopathic  Hospital,  but  did  not  improve.  The  above 
symptoms  continued  until  ten  years  ago,  when  she  began  to  have 
incontinence  of  urine,  which  has  continued  ever  since,  except  for  some 
periods  of  eight  to  ten  hours,  during  which  she  has  severe  pain. 

Physical  examination  shows  a  stout  woman,  good  color,  negative 
chest  and  abdomen,  lacerated  peritoneum,  exquisite  tenderness  over 
the  urethra.  On  the  12th  the  patient  was  anesthetized,  the  urethra 
dilated,  a  searcher  introduced,  and  a  stone  felt,  apparently  incrusted 
in  the  tissues  at  the  neck  of  the  bladder.  It  was  crushed  and  washed 
out.  The  fragments  examined  by  Dr.  W.  F.  Whitney  were  shown  to 
be  portions  of  phosphatic  calculus. 

Discussion. — So  long  a  history  of  frequency  and  incontinence, 
without  any  lesion  of  the  central  nervous  system,  makes  us  suspect 
an  organic  lesion  of  the  bladder,  benign  in  type — in  other  words,  a 
stone.  Subsequent  results  of  sounding,  and  the  position  of  the  stone 
in  the  neck  of  the  bladder,  make  it  probable  that  sphincteric  efficiency 
cannot  be  restored,  and  that  when  this  stone  is  removed  another  is 
quite  likely  to  re-form  in  the  old  ulcer  left  by  the  first. 

Outcome. — After  operation  the  patient  was  more  comfortable,  but 
still  incontinent  of  urine,  and  continued  so  at  the  time  of  discharge, 


FREQUENT   MICTURITION   AND   POLYURIA  505 

December  21st.  On  December  3,  1912,  the  patient  writes,  "I  am  no 
better  than  when  I  left  the  hospital,  in  some  ways  not  as  well,  as  I 
suffer  more  pain  now  than  I  did  then.  I  am  not  having  any  doctor 
now,  as  they  don't  seem  to  do  me  any  good.  Sometimes  I  think  I 
will  see  a  doctor  and  perhaps  he  can  give  me  something  for  the  pain, 
but  I  have  no  faith  in  any  of  them.  This  is  rather  a  hard  way  to 
talk  to  a  doctor." 

Case  218 

A  housewife  of  thirty-one,  born  in  Russia,  entered  the  hospital 
March  5,  1901,  for  the  first  time,  for  pelvic  pain,  which  had  been 
present  for  a  year  since  the  birth  of  her  last  child.  Operation  by  Dr. 
Maurice  H.  Richardson  showed  double  pyosalpinx.  One  tube  was 
removed,  and  on  the  other  a  plastic  operation  was  done  so  as  to  make 
possible  the  passage  of  the  ovum.  The  patient  convalesced  rapidly 
and  left  the  hospital  on  the  8th  of  April,  after  which  she  was  perfectly 
well  until  a  few  weeks  before  her  next  entrance  to  the  hospital,  Decem- 
ber 15,  1909,  when  she  began  to  be  bothered  very  much  by  frequent 
micturition,  constipation,  hemorrhoids,  and  pain  in  the  lumbar  re- 
gion. She  is  also  much  troubled  by  her  heart.  She  says  that  her 
urine  is  small  in  amount,  but  never  bloody. 

Physical  examination  shows  excellent  nutrition,  and  is  negative 
in  all  respects  except  for  very  slight  edema  over  the  shins.  The  blood 
and  urine  show  nothing  abnormal.  She  is  very  apprehensive  about 
her  heart. 

Discussion. — It  all  comes  to  this,  that  the  patient's  physical  ex- 
amination is  negative,  that  she  has  many  complaints  affecting  all 
parts  of  her  body,  and  especially,  as  I  see  it,  that  she  is  afraid  of  heart 
trouble.  This  point  is  of  importance,  and  it  may  well  be  that  by 
psychotherapy  addressed  to  cure  this  fear,  her  urinary  frequency  may, 
without  any  direct  attack,  be  conquered.  It  is  in  just  this  type  of 
case  that  we  must  hunt  for  psychic  and  social  causes  if  we  are  to  make 
treatment  effective.  We  ought  to  know  everything  we  can  about 
this  patient's  environment,  physical  and  psychic,  in  order  to  aid  her 
state  of  mind  if  we  are  to  help  her  bladder  symptoms. 

In  any  such  psychotherapy  the  first  and  most  important  step  is 
a  thorough  physical  examination  and  the  elimination  of  doubt,  first 
from  our  own  mind  and  then  from  the  patient's  mind,  regarding 
organic  disease.  In  the  first  instance,  it  does  not  seem  to  me  that 
cystoscopy  is  called  for  in  a  case  of  this  kind.  If  our  other  efforts  fail, 
we  must  come  back  to  that.     First,  we  should  try  the  effect  of  telling 


5o6 


DIFFERENTIAL  DIAGNOSIS 


the  patient  that  she  can  and  must  control  her  frequent  micturition. 
Patients  are  apt  to  think  that  dreadful  consequences  will  follow  any 
such  attempt  to  control.  When  they  are  assured  to  the  contrary,  they 
may,  within  a  day  or  two,  convince  themselves  of  their  power  to  check 
the  symptom  unassisted. 

Outcome. — When  reassured  about  her  heart  and  given  a  week's 
rest  she  was  able  to  control  the  frequency  of  micturition,  and  was 
finally  convinced  that  it  was  a  matter  of  habit.  She  left  the  hospital 
on  the  2oth. 

Case  219 

A  milliner  of  forty  entered  the  hospital  April  2,  1910.  Her  mother 
died  of  consumption  at  forty-six.  Her  family  history  is  otherwise 
good.     The  patient  herself  had  "typhoid  fever"  fifteen  years  ago. 


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Fig.  187. — Chart  of  Case  2ig  (first  entrance). 

Twelve  years  ago,  and  again  eight  years  ago,  she  raised  blood  in  small 
amounts.  On  the  second  occasion  she  was  awakened  from  sleep  by  the 
bleeding.  She  has  had  "bladder  trouble"  ever  since  she  was  a  child; 
i.  e.,  intermittent  attacks  of  frequency  and  burning  micturition. 
She  has  always  been  subject  to  severe  "colds."  Since  she  got  stout, 
four  years  ago,  she  has  had  some  shortness  of  breath. 

Ever  since  her  typhoid  she  has  noticed  that  her  legs  are  swollen 
at  night.  A  year  ago  she  had  no  menstruation  for  three  months,  but 
since  then  she  has  been  regular. 


FREQUENT   MICTURITION   AND   POLYURIA  507 

Ten  days  ago  she  "took  cold,"  and  began  to  have  bladder  trouble 
as  before.  The  next  day  she  had  chills,  headache,  and  pain  over  the 
pubes.     Last  night  she  vomited. 

On  physical  examination  she  was  well  nourished.  Her  chest  was 
negative,  except  for  a  soft  systolic  murmur  at  the  apex,  transmitted  to 
the  axilla.  Abdomen  negative.  At  entrance  the  diagnosis  was  of 
acute  infection  of  unknown  cause.  Next  day  the  patient's  scleras 
were  slightly  yellow.  The  urine  for  the  first  ten  days  averaged  20 
ounces  in  twenty-four  hours, 'then  rising  to  60  ounces  (Fig.  187). 
The  specific  gravity  varied  from  1013  to  102 1.  Pus  was  always 
present  in  the  sediment  in  large  amounts,  even  when  the  urine  was 
drawn  by  catheter.  At  entrance  the  blood  contained  28,000  leuko- 
cytes per  centimeter,  with  a  polynuclear  leukocytosis.  The  counts 
thereafter  were — April  4,  22,000;  April  7,  14,500;  April  13,  8000; 
April  27,  10,600.  Wassermann  reaction  was  negative.  Her  vomitus, 
April  4th,  contained  brownish  material  and  showed  positive  test  for 
guaiac.  On  the  loth  of  April  diminished  breathing  was  noticed  in 
the  right  back  and  diminished  excursion  of  the  lower  right  lung 
border. 

Cystoscopy,  April  nth,  by  Dr.  Hugh  Cabot,  showed  chronic 
cystitis.  The  ureters  looked  normal.  The  right  kidney  excreted 
indigocarmin  in  normal  time  and  amount.  The  left  kidney  ex- 
creted nothing  but  thick  yellow  pus.  Culture  from  the  urine,  which 
was  always  acid,  showed  only  a  slight  growth  of  cocci,  probably  due  to 
contamination.  Blood-cultures  were  negative;  i  cm.  of  urine  from 
the  left  ureter  was  injected  into  a  guinea-pig,  April  6th.  Autopsy, 
May  23d,  showed  nothing. 

Discussion. — There  is  a  good  deal  of  evidence  pointing  to  tubercu- 
losis in  this  case,  but  the  very  long  duration  of  her  symptoms,  thirty 
years  or  more,  makes  it  very  improbable  that  they  are  due  to  tuber- 
culosis. 

The  fifteen  years  of  edema  affecting  the  legs  is  probably  due  to 
phlebitis  after  typhoid,  and  has  no  connection,  I  take  it,  with  the 
present  trouble. 

She  now  comes  to  a  physician  by  reason  of  an  acute  upset,  ap- 
parently infectious  in  type,  and  associated  with  jaundice  and  pyuria 
in  a  urine  always  acid.  The  latter  fact  strongly  suggests  tuberculosis 
as  the  underlying  disease. 

Note,  in  the  first  temperature  charts  (Fig.  187),  how  the  tempera- 
ture goes  up  when  the  amount  of  urine  excreted  is  small  and  falls  as 
the  urine  increases.     This  might  be  due  either  to  retention  of  urine 


5o8 


DIFFERENTIAL  DIAGNOSIS 


during  a  period  of  infection  in  the  urinary  tract  or  possibly  to  a  con- 
centration of  urine  due  to  the  infection  itself. 

Cystoscopy  leaves  no  doubt  that  there  is  pus  in  the  kidney.  Since 
animal  inoculation  shows  no  tuberculosis,  and  no  sac  of  any  size  is 
to  be  felt  in  the  region  of  the  kidney,  we  may  exclude  tuberculosis 
and  pyonephrosis  and  conclude  that  a  pyelonephritis  of  septic  origin 
is  the  diagnosis. 

Outcome. — May  3d  the  left  kidney  was  cut  down  upon,  but  while 
being  stripped  of  its  fat  was  ruptured  and  pus  spilled  into  the  wound. 

Externally  the  kidney  was  soft 
and  somewhat  enlarged.  Neph- 
rectomy was  done.  Examination 
by  Dr.  W.  F.  Whitney  showed 
the  following:  Kidney,  13  by  4  by 
4I  cm.,  sacculated.  On  section, 
the  cortex  was  thin  and  the  Hning 
of  the  calices  and  pelves  thickened 
and  reddened.  Microscopic  ex- 
amination showed  entire  destruc- 
tion of  the  cortical  substance,  all 
of  the  glomeruli  being  sclerosed 
and  the  tubes  being  entirely  de- 
stroyed. The  tissue  was  every- 
where infiltrated  with  round  cells, 
many  of  them  leukocytes.  After 
operation  the  temperature  ranged 
high  for  a  long  time  (Fig.  188), 
with  a  positive  Widal  reaction. 
On  the  23d  of  June  some  pus 
pockets  were  opened  up.  July  19th  the  wound  was  better,  the  tem- 
perature was  lower,  and  the  patient  was  allowed  to  go  home. 

In  April,  19 13,  the  patient  reported  that  she  weighed  167  pounds, 
the  most  that  she  has  ever  weighed,  and  had  no  trouble  any  longer 
with  her  urine  except  the  frequency,  which  still  continued.  She 
passes  urine  four  times  in  the  night  and  four  times  in  the  day.  If  she 
is  prevented  from  emptying  the  bladder  she  gets  fits  of  shivering. 
She  says  that  she  is  very  nervous  and  has  no  strength.  Nevertheless, 
she  is  pursuing  her  trade  as  a  milliner. 

Remarks. — How  should  we  interpret  the  persistence  of  a  positive 
Widal  reaction?  Probably,  I  think,  as  a  result  of  typhoid  infection 
remaining  in  the  gall-bladder.     There  seems  no  evidence  of  typhoid 


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patient's  second  hospital  stay  (Case  219). 


FREQUENT   MICTURITION   AND    POLYURIA 


509 


in  the  urinary  tract,  or  of  any  generalization  of  the  process  such  as 
results  in  what  we  call  typhoid  fever. 

There  are  other  cases  on  record  in  which  typhoid  infection  has 
remained  in  the  gall-bladder  after  typhoid  fever  for  periods  much 
longer  than  fifteen  years. 

Case  220 

A  housewife  of  thirty-eight  entered  the  hospital  April  5,  19 10. 
Her  family  history  was  excellent.  The  patient  had  "pneumonia  and 
pleurisy"  two  and  a  half  years  ago,  otherwise  has  been  well,  and  has 
had  nine  healthy  children  and  three  miscarriages.  Last  fall  she  felt 
run  down,  but  picked  up  until 
five  weeks  ago,  when  she  began 
again  to  feel  weak  and  tired. 
Of  late  there  has  been  occa- 
sional incontinence  of  urine  with 
some  frequency.  Incontinence 
and  weakness  are  now  her  chief 
symptoms. 

Physical  examination  showed 
poor  nutrition,  moderate  fever 
(Fig.  189).  The  pupils  were  un- 
equal in  size,  shghtly  irregular, 
and  react  slowly.  Lymph-nodes, 
the  size  of  beans,  were  felt  in 
the  right  axilla.  Chest  nega- 
tive. Reflexes  and  urine  nor- 
mal. Abdomen  as  in  Fig.  190. 
The  patient  remained  a  month 
in  the  wards  without  any  gain  in 

weight,  but  with  considerable  gain  in  strength.      The  skin  tuber- 
culin reaction  was  slightly  positive.     Bowels  rather  costive. 

Discussion. — The  diagnosis  seems  to  be  tuberculous  peritonitis. 
Just  what  is  the  relation  of  this  to  the  urinary  frequency  I  do  not  know. 
With  a  perfectly  normal  urine  we  have  no  good  reason  to  suspect 
tuberculosis  of  the  bladder  or  kidney.  If  tuberculous  peritonitis  is  a 
correct  diagnosis,  it  may  well  be  that  there  are  glandular  masses  around 
the  bladder  which  interfere,  possibly,  with  its  action.  Possibly  her 
general  weakness  affects  the  sphincteric  control  and  contributes  to  or 
causes  her  frequency.  The  case  is  an  unusual  one  and  not  altogether 
explained. 


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Sio 


DIFFERENTIAL  DIAGNOSIS 


Outcome. — She  went  home  on  the  20th,  much  relieved.  The 
patient  died  in  September,  19 10.  Her  daughter  writes  that  she  got 
along  nicely  after  leaving  the  Massachusetts  General  Hospital  until  a 
nurse  came. to  the  house  and  told  her  that  it  had  been  reported  that 


Fig.  190. — Condition  of  the  abdomen  in  Case  220. 

she  was  a  consumptive.  "After  that  she  worried  and  pined  herself 
away."  Her  physician,  Dr.  W.  P.  Cross,  of  South  Boston,  writes 
that  she  died  of  pulmonary  tuberculosis. 


Case  221 

An  Armenian  tailor  of  twenty-five  entered  the  hospital  March  9, 
1910.  His  family  history  and  habits  are  good.  Ten  years  ago  he  had 
some  trouble  with  his  left  hip,  lasting  three  months.  A  year  ago  he 
began  to  have  slight  pain  in  the  region  of  the  right  costovertebral 
angle,  troubling  him  both  by  day  and  by  night,  and  radiating  down  his 
back  and  to  the  groin.  This  was  accompanied  by  frequency  of  mic- 
turition, at  first  every  five  to  twenty  minutes.  The  urine  was  bloody 
and  painful  in  passage.  For  three  months  he  has  been  having  similar 
pain  in  the  left  side.     During  the  past  fifteen  days  he  has  passed  a 


FREQUENT  MICTURITION   AND   POLYURIA 


;ii 


number  of  times  what  he  calls  "pieces  of  meat."  For  three  weeks  his 
appetite  has  been  poor,  bowels  have  been  irregular,  and  his  sleep  poor. 
A  year  ago  he  weighed  135  pounds;  now,  141  pounds.  He  has  done  no 
work  in  the  past  year  and  "feels  tired." 

Physical  examinations,  including  rr-ray  and  the  blood,  were  nega- 
tive, except  that  the  left  leg  was  slightly  atrophied  and  the  hip  motions 
limited.  The  urine  averaged  40  ounces  in  twenty-four  hours;  specific 
gravity,  1016;  albumin,  0.2  per  cent.  The  sediment  contained  much 
pus  and  blood.  There  were  no  tubercle  bacilli  and  no  casts.  Tem- 
perature was  as  shown  in  Fig.  191.  On  the  nth  of  April  a  few  acid- 
fast  bacilli  were  found  in  the  sediment  of  the  urine  obtained  under 
aseptic  precautions.  March  14th  cystoscopy  by  Dr.  Hugh  Cabot 
showed  that  the  bladder  was 
much  contracted  and  ulcerated. 
Indigocarmin-  excretion  was 
very  poor,  and  not  enough  com- 
ing from  either  kidney  in  half 
an  hour  to  make  clear  the  posi- 
tion of  the  ureter.  The  condi- 
tion was  believed  to  be  an  ad- 
vanced bilateral  tuberculosis, 
but  another  cystoscopy,  April 
1 8th,  showed  that  the  right  kid- 
ney now  excreted  indigocarmin 
promptly  and  in  full  amount, 
while  none  at  all  came  from  the 
left  side  in  thirty-five  minutes. 
A  cubic  centimeter  of  urine  from 
the  left  kidney  was  injected  into 
a  guinea-pig  April  14th.  Au- 
topsy, May  23d,  showed  tuber- 
culosis of  the  spleen  and  liver. 

The  urine  was  always  acid  during  the  patient's  hospital  stay.  He  com- 
plained of  considerable  pain  in  the  right  flank  at  times.  The  bladder 
held  only  3  ounces.  He  gained  4  pounds  during  his  stay  in  the  medical 
wards,  where  the  treatment  consisted  of  sandalwood  oil,  10  minims, 
three  times  a  day,  and  an  occasional  dose  of  aspirin  or  phenacetin, 
with  a  maximum  of  fresh  air  and  food. 

Discussion. — A  point  of  interest  is  that  the  pain  was  mostly  on 
the  right  side,  though  the  disease  was  mostly  on  the  left.  This  not 
infrequently   happens   in   tuberculous  disease   of   the  kidney.     One 


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-Chart  of  Case  221  up  to  the  day 
of  operation. 


512  DIFFERENTIAL  DIAGNOSIS 

side  becomes  diseased,  the  other  kidney  hypertrophies,  and  in  con- 
nection with  this  hypertrophy  there  may  be  pain.  This  leads  to  an 
examination  of  the  kidney  region.  We  feel  the  hypertrophied  kidney 
and  decide  that  it  is  diseased.  The  sick  organ  on  the  other  side  mean- 
time keeps  quiet. 

Note  that  the  urine  contains  blood,  which  is  somewhat  unusual 
in  renal  tuberculosis. 

Note  further  that  there  is  actual  tuberculosis  of  the  bladder. 
In  many  cases  of  renal  tuberculosis  the  bladder  is  normal,  despite 
the  very  marked  urinary  frequency  and  pain.  This  case  is  one  of  the 
exceptions. 

Outcome. — On  the  23d  the  left  kidney  was  cut  down  upon.  The 
kidney  seemed  small,  but  otherwise  not  abnormal,  as  was  the  left 
ureter.  The  right  kidney  was  hypertrophied  and  was  considered 
tuberculous,  while  the  left  was  merely  somewhat  atrophied.  It  was 
deemed  unwise  to  remove  the  left  kidney  on  the  ground  that  the  other 
was  also  diseased.  It  was  thought  that  the  condition  of  the  left 
kidney  was  not  such  as  to  account  for  the  urine.  The  patient  did 
well  after  operation,  except  for  an  attack  of  scarlet  fever,  but  a  letter 
from  his  son  tells  us  that  he  died  three  months  after  leaving  the 
hospital. 

Case  222 

A  Scotch  motorman  of  forty-three  entered  the  hospital  May  18, 
1910.  The  patient's  father  died  of  "inflammation  of  the  bowels"; 
otherwise  nothing  of  importance  was  contained  in  the  family  history. 
The  patient  had  "rheumatism"  in  his  back  and  hip  seven  or  eight 
years  ago,  and  was  confined  to  bed  two  months  at  that  time.  Other- 
wise his  past  history  and  habits  are  good. 

For  seven  or  eight  years  he  has  noticed  that  in  certain  positions 
he  had  twinges  of  pain  and  a  sense  of  something  moving  in  the  right 
flank.  During  the  same  period  he  has  had  to  pass  urine  about  every 
three  hours,  night  and  day.  He  thinks  the  total  amount  is  not  in  • 
creased.  Several  times  during  the  last  six  years  he  has  passed  small 
clots  of  blood,  and  in  the  last  month  this  has  happened  two  or  three 
times  a  week.  During  the  past  winter  he  often  felt  lame  in  the 
right  lower  quadrant  after  a  day's  work,  and  on  lying  down  sometimes 
felt  soreness  beneath  the  left  ribs.  His  discomforts  are  always  worse 
on  exertion  and  always  relieved  by  passing  urine. 

All  winter  he  has  had  slight  cough  and  some  expectoration,  and 
on  his  car  has  noticed  shortness  of  breath  and  some  fatigue.     For 


FREQUENT  MICTURITION   AND    POLYURIA 


513 


the  past  month  these  symptoms  have  been  accompanied  by  dizzy 
spells  and  frequent  nausea  when  getting  off  his  car  at  the  end  of  his 
run.  His  appetite  during  the  past  month  has  been  poor  and  he  has 
had  some  headache.  He  weighed  himself  four  weeks  ago  and  found 
he  had  lost  12  pounds.  Since  that  time  he  has  lost  about  12  pounds 
more.     He  quit  work  eleven  days  ago. 

Physical  examination  showed  good  nutrition  and  slight  pallor. 
The  heart's  apex  extended  2  cm.  outside  the  nipple  line.  The  pul- 
monic second  sound  was  accentuated.  There  were  no  murmurs  or 
other  abnormalities.  There  was  slightly  diminished  breathing  at 
the  right  base  behind.     Otherwise  the  lungs  are  normal.     The  ab- 


Fig.  192. — Outlines  of  mass  felt  in  Case  222. 

domen  showed  a  mass,  the  outlines  of  which  are  shown  in  Fig.  192; 
otherwise  nothing  abnormal. 

During  his  two  weeks'  stay  in  the  hospital  his  temperature  occa- 
sionally rose  to  99.5°  or  100°  F.,  but  was  usually  normal.  He  lost 
4  pounds  in  weight  in  this  period.  The  urine  averaged  40  ounces  in 
twenty-four  hours;  specific  gravity,  1020;  albumin,  yV  per  cent,  or 
less.  The  sediment  consisted  chiefly  of  pus,  which  made  up  about 
one-tenth  of  the  specimen.  No  tubercle  bacilK  were  present  in  it. 
The  blood  contained  from  15,000  to  18,000  leukocytes  per  cubic 
millimeter,  with  a  polynuclear  leukocytosis.  Hemoglobin,  85  per 
cent.;  blood-pressure,  150  mm.  Hg. 

Vol.  11—33 


514  DIFFERENTIAL  DIAGNOSIS 

Cystoscopy  by  Dr.  Hugh  Cabot  showed  that  the  bladder  held 
6  ounces.  There  was  marked  ulceration  of  the  right  lateral  wall 
and  about  the  right  ureter,  from  which  a  "worm"  of  thick  yellow 
pus  issued.  No  excretion  of  color  or  urine  from  it.  The  left  side 
and  ureter  appeared  normal  and  secreted  indigocarmin  eight  and 
one-haK  minutes  after  injection  and  in  normal  amount.  After 
the  cystoscopy  he  had  to  be  catheterized  during  the  ten  days  pre- 
ceding his  transfer  to  the  surgical  ward.  The  diagnosis  was  right 
pyonephrosis,  probably  tuberculous.  Twenty  minims,  drawn  by 
catheter  from  the  right  ureter,  were  injected  May  19th  into  a  guinea- 
pig.  Autopsy,  June  29th,  showed  tuberculous  lesions  of  the  glands 
and  spleen.  The  patient  was  entirely  comfortable  in  the  ward.  A 
skin  tuberculin  reaction  was  strongly  positive.  The  urine  was  always 
acid. 

Discussion. — The  duration  of  the  patient's  symptoms  is  of  inter- 
est. Apparently  he  has  had  something  the  matter  with  his  kidneys 
for  eight  years,  yet  he  has  got  along  fairly  well  and  done  his  work 
until  eleven  days  ago.  In  view  of  the  diagnosis,  to  be  mentioned  in  a 
moment,  this  is  of  much  interest.  The  fact  that  his  pain  was  always  re- 
Heved  by  micturition  connects  it  very  certainly  with  the  urinary  tract. 

It  is  important  to  note  that  he  has  had  cough  and  loss  of  weight 
for  six  months,  with  other  symptoms,  such  as  vertigo,  headache,  and 
nausea,  pointing  to  some  infectious  disease. 

In  advance  of  the  cystoscopic  examination  we  can  conclude,  in 
the  presence  of  fever,  leukocytosis,  pyuria,  and  a  mass  in  the  region 
of  the  right  kidney,  that  he  has  pus  in  or  about  that  organ.  The 
presence  of  cough  and  emaciation  gives  us  ground  to  conjecture 
that  his  kidney  may  be  tuberculous. 

Cystoscopy  increases  the  probability  of  this  hypothesis,  and  the 
results  of  animal  inoculation  prove  it. 

Outcome. — June  3d  the  kidney  was  cut  down  upon  and  found  very 
adherent,  greatly  enlarged,  and  fluctuant.  The  kidney  was  removed. 
No  attempt  was  made  to  resect  the  ureter.  Pathologic  examination 
by  Dr.  W.  F.  Whitney  was  as  follows:  Kidney,  13  by  5  cm.,  sacculated 
and  filled  with  pultaceous  material,  consistency  very  soft  and  putty- 
like. Cortex  thin.  Microscopic  examination  showed  the  cortex  ex- 
tremely infiltrated  with  round  cells,  and  here  and  there  small  foci  of 
rounded  and  epitheHoid  cells  with  giant  cells  and  cheesy  degeneration. 
Tuberculosis. 

The  patient  did  well  after  opjeration,  and  was,  discharged  June  2  2d 
in  excellent  condition. 


FREQUENT  MICTURITION   AND   POLYURIA  515 

In  the  spring  of  19 13  the  patient  reported  himself  to  be  in  perfect 
health,  stouter  than  ever,  and  working  steadily  since  September,  19 10. 
Such  perfect  results  in  renal  tuberculosis  are  among  the  most  satis- 
factory in  medicine  and,  fortunately,  they  are  not  very  rare. 

Case  223 

An  Armenian  butcher  of  thirty-eight  entered  the  hospital  June  3, 
1910.  In  1903  the  patient  began  to  have  trouble  with  frequency  of 
micturition.  This  continued  to  trouble  him,  but  was  unaccom- 
panied by  any  other  symptoms  until  one  year  ago,  when  he  noticed 
slight  swelling  of  his  legs  with  shortness  of  breath  and  fatigue  on 
exertion.  During  the  last  four  weeks  his  eyesight  has  been  growing 
poor,  and  for  two  weeks  he  has  had  orthopnea  and  been  unable  to 
sleep  in  bed.  Cough  and  night-sweats  have  also  been  troublesome. 
He  thinks  he  has  lost  weight.  In  former  years  he  has  had  a  great 
deal  of  generahzed  headache;  for  the  past  three  months,  none.  He 
has  rather  frequent  nosebleeds.  Seven  months  ago  he  weighed 
145  pounds;  now,  128  pounds.  He  has  had  no  previous  illness  except 
"stomach  trouble,"  in  1893,  for  which  he  was  treated  in  the  Out-patient 
Department.  Diarrhea  and  pain  after  eating,  with  occasional  vomit- 
ing, were  his  symptoms  at  that  time.  He  was  sick  three  months, 
but  has  ever  since  been  well  and  strong  until  the  present  illness. 
His  family  history  is  good.  His  wife  has  had  three  healthy  children, 
one  child  still-born,  one  miscarriage. 

The  patient  was  well  nourished,  and  breathed  easily  but  rapidly 
as  he  sat  propped  up  in  bed.  On  his  left  cheek  was  the  scar  of  an 
Aleppo  boil  (Leishmaniasis) .  Pupils,  glands,  and  reflexes  were  normal. 
The  heart's  area  of  dulness  extended  5  cm.  outside  the  nipple,  in  the 
sixth  interspace,  and  2I  cm.  to  the  right  of  the  median  Hne.  There 
were  no  murmurs.  Its  action  was  regular,  slightly  rapid.  The 
pulmonic  second  was  louder  than  the  aortic  second.  The  artery 
walls  were  thickened.  The  brachials  show  lateral  excursion.  The 
systoHc  blood-pressure  was  210  mm.  Hg.  in  the  right  arm_,  180  in  the 
left,  and  the  right  radial  pulse  was  markedly  greater  than  the  left. 
The  blood-pressure  was  measured  sixteen  times  during  his  three  weeks 
and  a  half  in  the  hospital.  It  remained  at  about  the  same  level, 
and  also  showed  approximately  the  same  discrepancy  between  the  two 
arms. 

At  the  base  of  the  right  axilla  and  below  the  angle  of  the  scapula, 
on  the  right  side,  posteriorly,  there  was  dulness,  absent  breath  sounds, 
and  voice  sounds.     The  abdomen  was  negative,  except  that  the  edge 


5l6  DIFFERENTIAL   DIAGNOSIS 

of  the  liver  could  be  vaguely  felt  i  inch  below  the  ribs.  He  had 
moderate  edema  of  the  legs  and  sacrum.  The  blood  showed  nothing 
abnormal.  The  urine  averaged  30  ounces  in  twenty-four  hours; 
specific  gravity,  1009  to  1012;  albumin,  0.25  to  0.50 per  cent.;  sediment, 
hyaline  and  granular  casts,  with  cells  and  fat  adherent.  Wassermann 
reaction  was  negative. 

During  his  stay  in  the  hospital  the  patient  was  quite  comfortable 
during  the  day,  and  his  lungs  at  that  time  were  usually  clear,  except 
in  the  area  above  noted.  But  at  night  he  had  a  terrible  time  of  it, 
wheezed  alarmingly,  and  had  to  sit  leaning  forward  in  a  chair  in  order 
to  breathe.  The  attacks  were  not  at  all  relieved  by  inhalation  of  stra- 
monium, cubebs,  or  potassium  nitrite,  and  even  morphin  did  not  give 
him  relief.     Hot-air  baths  seemed  more  efficient. 

By  the  9th  he  was  distinctly  better,  and  was  able  to  sleep  through 
the  night,  except  for  one  slight  attack.  Theocin,  5  gr.  three  times 
a  day,  had  no  special  effect.  Digipuratum  was  equally  ineffective. 
By  the  14th  the  lungs  were  entirely  clear,  and  there  was  no  edema  of 
the  legs,  except  after  being  up  all  day,  but  as  soon  as  he  began  to  be 
up  and  about  the  ward  he  got  worse  again  and  the  night  attacks  re- 
curred. He  was  then  put  back  upon  his  daily  hot-air  baths  and 
marked  relief  followed.  By  the  24th  he  was  again  sleeping  all  night, 
and  was  thereafter  able  to  be  up  and  about  all  day,  free  from  all 
evidence  of  decompensation,  except  slight  edema  of  the  legs. 

He  left  the  hospital  on  the  28th  of  June,  and  returned  on  the  5th 
of  July,  1 9 10,  having  been  much  worse  since  he  left  the  hospital. 
At  this  time  the  systoKc  blood-pressure  was  230  mm.  Hg.  in  the 
right  arm,  200  in  the  left.  His  blood  showed  20,000  leukocytes,  with 
81  per  cent,  polynuclear  cells,  although  fever  and  all  evidences  of 
inflammation  were  absent.  His  urine  was  practically  as  before. 
At  entrance  he  was  fighting  for  breath,  sweating  profusely,  and  looked 
very  pale,  although  his  hemoglobin  was  80  per  cent.  There  was 
some  ascites  and  occasional  vomiting.  All  these  symptoms  continued 
for  about  forty-eight  hours,  during  which  time  morphin  was  the  chief 
aid  given.  After  that  hot-air  baths  were  started,  and  with  these  and 
10  minims  of  digitalis,  three  times  a  day,  he  showed  a  wonderful 
improvement. 

In  five  days  his  edema  was  gone  and  he  had  changed  from  a  fat 
to  a  thin  man.  The  cardiac  and  pulmonary  signs  were  practically  as 
before  described;  during  the  attacks  of  dyspnea  his  expiration  was 
always  prolonged,  intensified,  and  accompanied  with  wheezing  rales 
("renal  asthma").     At  times  his  dyspnea  was  very  great,  and  was 


FREQUENT  MICTURITION   AND   POLYURIA  517 

relieved  only  by  standing  up  and  leaning  upon  the  back  of  a  chair. 
On  the  2  2d  of  July  his  right  chest  was  tapped  and  1900  c.c.  of  slightly 
cloudy,  yellow  fluid  removed.  Its  specific  gravity  was  1006;  albumin, 
0.5  per  cent.;  sediment,  mostly  endothehal  cells,  with  a  few  polynu- 
clears  and  lymphocytes.  After  this  tapping  there  was  a  loud,  dry, 
painful  friction  rub,  audible  over  the  entire  right  back.  Ice-pack  and 
morphin  were  required  for  its  rehef.  The  blood  at  this  time  showed 
14,000  white  cells,  81  per  cent,  of  polynuclears. 

After  the  pleural  pain  had  subsided  the  patient  was  much  more 
comfortable,  but  early  in  August  he  became  very  drowsy  and  his 
dyspnea  gradually  increased.  The  fluid  re-accumulated  m  his  right 
chest,  and  on  the  4th  of  August  1350  c.c,  with  a  specific  gravity  of 
1009,  were  removed.  Things  seemed  to  be  going  on  from  bad  to  worse, 
and  on  the  5  th  of  August  the  patient  was  given  15  gr.  of  diuretin 
at  2,  3,  and  4  P.  m.  His  digitalis  was  increased  to  25  minims,  three 
times  a  day,  his  h'quids  limited  to  1000  c.c.  After  that  his  condition 
markedly  improved  for  a  time.  His  urine  output  increased  to  60 
ounces,  his  hydrothorax  and  edema  diminished,  and  he  was  able  to 
sleep  for  several  nights  without  sedatives.  A  week  later  he  began  to 
lose  ground  steadily.  His  chest  was  tapped  again  on  the  23d  of 
August;  1000  c.c.  were  removed;  again,  on  the  27th,  850  c.c.  were 
withdrawn.  The  characteristics  of  the  fluid  were  as  before.  On 
the  12th  of  September  he  died. 

Discussion. — Here  the  frequency  is  associated  with  headache,  and 
lately  with  dyspnea,  edema,  and  poor  sight.  This  differentiates 
the  case  sharply  from  those  previously  discussed.  With  the  appear- 
ance of  orthopnea  and  cough  in  the  last  two  weeks,  we  have  every 
reason  to  expect  the  hypertension  and  urinary  abnormalities  which 
physical  examination  reveal. 

The  leukocytosis  at  the  time  of  his  second  entrance  to  the  hospital 
may  have  been  of  the  uremic  t3^e  or  may  have  been  connected  with  a 
terminal  septicemia.  The  dyspnea  at  this  time  was  of  the  type  often 
known  as  renal  asthma. 

The  point  of  special  interest  in  the  whole  case  is  that  the  first 
of  all  his  symptoms  was  urinary  frequency.  In  the  form  of  nocturia 
this  symptom  is  often  the  earliest  manifestation  of  renal  disease, 
but,  unfortunately,  it  is  often  overlooked  by  physicians  as  they  take 
their  patients'  histories.  In  my  own  routine  I  never  omit  to  ask  about 
nocturia  in  connection  with  the  other  routine  questions  regarding 
appetite,  bowels,  sleep,  and  weight. 

Outcome. — ^Autopsy,  No.  2676,  showed  chronic  glomerulonephritis; 


5l8  DIFFERENTIAL   DLA.GNOSIS 

arteriosclerosis  of  the  aorta  and  coronary  arteries;  myomalacia  of  the 
left  ventricular  wall  near  the  apex,  with  mural  thrombi  on  the  corre- 
sponding area  of  endocardium;  hypertrophy  and  dilatation  of  the 
heart,  acute  terminal  pericarditis,  general  passive  congestion,  drop- 
sical effusion  in  the  serous  ca\dties;  obsolete  tuberculosis  of  a  tracheal 
l}Tnphatic  gland.  The  cause  of  the  difference  in  blood-pressure  in 
the  two  arms  was  not  explained. 

Case  224 

A  housewife  of  forty-three  entered  the  hospital  November  lo,  1910. 
The  patient  has  had  eight  healthy  children  and  seven  miscarriages. 
During  her  last  pregnancy,  three  and  one-half  years  ago,  she  spent 
three  weeks,  at  the  fourth  month,  in  the  Maternity  Hospital  on  West 
Newton  Street,  where  she  was  said  to  have  albuminuria  and  "acute 
diabetes."  Carbohydrates  were  restricted,  she  was  delivered  of  a 
healthy  child  at  term,  and  remained  well  until  the  present  illness. 

Since  early  summer  she  has  gradually  become  more  and  more 
tired  and  irritable.  She  thinks  the  amount  of  urine  has  been  increas- 
ing, and  is  quite  sure  she  passes  it  more  frequently  than  is  normal. 
Two  days  ago  she  vomited,  and  this  symptom  has  continued  night  and 
day  since  that  time.     Yesterday  she  began  to  have  some  headache. 

Visceral  examination  is  entirely  negative.  The  urine  averages 
30  ounces  in  twenty-four  hours,  specific  gravity  usually  about  1012; 
it  contained  a  few  hyaline  casts,  but  nothing  else  abnormal  in  the 
sediment.  After  the  17th  of  November  albumin  was  absent.  On 
the  nth  and  12th  of  November  no  sugar  was  present  in  the  urine. 
On  the  13th,  15th,  and  17th  traces  were  found,  the  amount  being 
from  0.4  to  0.6  per  cent.  Blood-pressure,  135  mm.  Hg.  The  blood 
at  entrance  showed  hemoglobin,  90  per  cent.;  leukocytes,  19,000, 
faUing  in  two  days  to  12,000.  Vomiting  was  easily  controlled  by 
starvation  for  twenty-four  hours,  during  which  time  she  was  given 
cracked  ice  by  mouth  and  6  ounces  of  normal  sahne  solution  by 
rectum  every  four  hours.  November  nth  she  began  to  take  milk 
and  lime-water,  2  to  i,  2  ounces  every  two  hours,  and  the  amount  of 
food  was  doubled  next  day.  After  the  first  twenty-four  hours  there 
was  no  vomiting  and  no  other  S3rmptoms  of  importance,  and  on  the 
1 6th  she  felt  fine  and  was  out  of  bed. 

Discussion. — The  case  is  an  obscure  one.  For  six  months  the 
frequency  has  been  associated  with  a  psychic  irritability,  which  may 
be  its  cause  or  its  concomitant.  The  appearance  of  headache  and 
vomiting  within  the  last  two  days,  and  the  sUght  albuminuria  and- 


FREQUENT  MICTURITION   AND   POLYURIA  519 

glycosuria,  may  also  be  either  the  cause  or  the  result  of  the  psychic 
disturbances.  Frequency,  as  we  know,  may  be  associated  not  only 
with  diabetes,  but  with  the  psychic  type  of  glycosuria.  The  diffi- 
culty of  such  an  explanation  in  the  present  case  is  that  the  amount  of 
sugar  is  so  small.  Possibly  when  the  symptoms  began  and  the  fre- 
quency was  at  its  height,  she  may  have  had  more  glycosuria  than  she 
did  under  our  observation.  The  point  of  greatest  importance  in  the 
whole  case  is  the  total  disappearance  of  all  symptoms  in  the  end. 
Possibly,  when  we  know  more  about  the  action  of  the  ductless  glands 
a  case  hke  this  may  be  explained  by  some  temporary  excess  or  defi- 
ciency in  that  function.  For  the  present  it  remains  rather  mysterious. 
Outcome. — November  13th  she  was  given  egg-nogs,  toast,  crackers, 
and  on  the  14th  a  normal  diet.  By  November  2  2d  she  seemed  per- 
fectly well. 

Case  225 

A  housewife  of  forty-seven  entered  the  hospital  December  28,  1910. 
The  patient's  mother  died  of  phthisis  at  thirty-five  and  her  father  of 
kidney  trouble  at  fifty.  From  girlhood  she  was  always  delicate  and 
subject  to  sore  throats  and  headaches,  especially  when  nervous  or 
excited.     Often  these  headaches  are  accompanied  by  vomiting. 

Three  years  ago  she  had  pain  in  the  left  side  of  the  abdomen,  which 
was  diagnosed  as  "fibroid  of  the  uterus."  Ever  since  that  time  she 
has  had  a  little  of  the  same  pain,  off  and  on. 

For  a  year  she  has  had  constant  dull  epigastric  pain,  sometimes 
very  severe,  radiating  to  both  breasts,  both  shoulders,  and  the  small 
of  the  back,  sometimes  waking  her  at  night,  and  temporarily  relieved 
by  taking  a  raw  egg  and  brandy  or  by  other  food.  Otherwise  the 
pain  seems  to  have  no  relation  to  meals.  The  patient's  menstruation 
ceased  seven  years  ago. 

For  a  month  her  epigastric  pain  has  been  much  more  severe.  It 
is  constant  with  sharp  exacerbations,  perhaps  a  dozen  times  a  day, 
and  without  known  cause.  The  appetite  is  very  variable,  and  she  is 
afraid  to  eat.  She  passes  urine  a  dozen  to  fifteen  times  a  day  and  once 
or  twice  in  the  night.  During  the  past  month  the  urine  has  been  very 
high  colored.  She  thinks  she  has  been  losing  weight  for  a  year  and  a 
half,  but  worked  until  five  weeks  ago. 

On  physical  examination  the  patient  is  pale  and  thin,  shows  a 
lymph-node  the  size  of  a  filbert  over  the  right  clavicle,  and  several 
large  nodes  in  the  left  groin.  The  other  lymph-nodes  are  not  abnormal. 
For  the  chest,  see  Fig,  193.     The  abdomen  showed  masses  as  de- 


520 


DIFFERENTIAL   DIAGNOSIS 


lineated  in  Fig.  193.  The  pelvis  is  filled  with  a  hard,  somewhat  elastic, 
apparently  cystic  mass.  The  cervix  is  pushed  close  behind  the  pubic 
bone  and  the  uterus  to  the  right. 

Discussion. — Presumably  the  family  history  of  tuberculosis  is  not 
of  importance,  as  there  is  nothing  in  the  patient's  present  condition 
to  suggest  any  form  of  that  disease.  The  abdominal  tumor  is  not 
likely  to  be  produced  by  tuberculous  peritonitis.  The  symptoms  of 
the  past  year  were  such  as  at  first  to  suggest  gall-stones,  but  during 
the  past  month  the  pain  has  been  much  too  constant  to  be  explained 


Fig.  193. — Chest  and  abdomen  of  Case  225. 


in  that  way.     Whether  it  is  connected  with  the  pelvic  lesion  asso- 
ciated with  the  frequency  it  is  difficult  to  say. 

What  is  the  nature  of  the  pelvic  mass?  The  patient's  emaciation 
and  the  nodule  above  the  clavicle  are  ominous  signs,  unless  we  can 
explain  the  latter  as  a  relic  of  the  old  tuberculous  trouble — a  rather 
far-fetched  hypothesis.  Our  attempts  to  make  the  case  out  tuber- 
culous are  not  successful,  and  if  this  is  excluded  we  have  every  reason 
to  fear  malignant  disease,  perhaps  originating  in  an  ovary.  The 
lung  signs  are  much  less  significant  than  they  would  be  if  they  had 


FREQUENT  MICTURITION   AND   POLYURIA  $21 

occurred  upon  the  other  side.     I  am  not  at  all  sure  that  they  are  not 
physiologic. 

Outcome. — Operation  was  advised,  but  refused.  She  went  home 
January  5,  191 1,  and  died  within  that  month. 

Case  226 

A  cook  of  fifty-eight  entered  the  hospital  March  2,  191 1.  The 
patient's  family  history  is  not  important.  Three  years  ago  he  vomited 
a  large  amount  of  blood,  having  four  attacks  of  this  trouble  within 
two  weeks  and  remaining  in  the  hospital  for  that  period.  Two  years 
ago  he  began  to  notice  increasing  frequency  of  micturition,  and  thinks 
this  was  due  rather  to  an  inability  to  hold  his  water  than  to  an  in- 
crease in  amount  passed.  This  troubled  him  intermittently,  but  has 
gradually  grown  worse,  until  now  it  prevents  his  working.  He  has 
never  had  pain  or  retention  or  seen  any  blood  in  the  urine.  He  now 
passes  water  eight  to  ten  times  a  day  and  six  to  eight  times  at  night. 

For  six  months  he  has  noticed  slight  dyspnea  on  exertion,  and  has 
needed  three  pillows  under  his  head  at  night.  He  has  a  voracious 
appetite.     No  headache,  no  loss  of  weight,  no  edema. 

Physical  examination  showed  good  nutrition  and  no  anemia. 
Heart's  apex  extends  i  cm.  outside  the  nipple  line  and  the  retrosternal 
dulness  seemed  to  be  increased  at  the  level  of  the  second  rib.  At 
the  apex  and  in  the  aortic  area  a  systolic  murmur  was  heard.  Aortic 
second  was  sharp  and  ringing.  Systolic  blood-pressure  at  entrance, 
300,  and  ranged  above  250  during  the  first  week  of  his  stay.  In 
the  next  two  weeks  it  was  usually  in  the  vicinity  of  230,  with  occa- 
sional spurts  up  to  280.  After  that  it  ranged  between  220  and  250, 
until  he  left  the  hospital,  April  15th.  The  lungs  and  abdomen 
showed  nothing  abnormal.  The  pupils  were  irregular,  but  reacted 
normally.  Reflexes  negative.  The  prostate  was  slightly  enlarged 
by  rectum,  but  cystoscopy  showed  no  intravesical  prostatic  enlarge- 
ment. The  bladder  was  trabeculated,  but  not  inflamed,  and  emptied 
itself  rapidly  and  freely.  Dr.  Hugh  Cabot  believed  the  condition 
to  be  dependent  upon  the  heart.  Later,  the  pupils  seemed  to  react 
somewhat  sluggishly  and  the  question  of  tabes  and  a  tabetic  bladder 
was  seriously  considered.  The  urine  ranged  from  50  to  80  ounces  in 
twenty-four  hours.  Specific  gravity,  loio  to  1012,  usually  near  the 
lower  figure.  Many  hyaline  and  granular  casts  with  round  cells  and 
leukocytes  adherent  were  found.  The  Wassermann  reaction  was  nega- 
tive. 

Additional  history  obtained  from  the  patient's  wife  showed  that 


522  DIFFERENTIAL   DIAGNOSIS 

the  patient  had  been  bothered  for  five  years  by  attacks  of  weakness 
in  his  legs,  occasionally  accompanied  by  pain  throughout  his  thighs 
and  calves.  After  such  attacks  his  legs  remained  sore.  During  the 
same  period  he  has  become  much  more  irritable,  and  has  sometimes 
awakened  in  the  night  somewhat  dazed,  not  knowing  where  he  is. 
His  wife  states,  however,  that  he  has  had  enough  trouble  in  this  period 
to  change  his  disposition. 

Discussion. — There  seems  no  good  sense  in  connecting  the  patient's 
hemoptysis  of  three  years  ago  with  his  present  symptoms.  What  was 
the  cause  of  that  hemoptysis  we  have  no  means  of  judging. 

His  frequency,  which  antedated  all  his  other  symptoms  except  the 
hemoptysis,  begins  to  get  its  explanation  as  soon  as  we  know  that  he  has 
dyspnea  and  orthopnea,  and  becomes  clearly  recognized  as  a  mani- 
festation of  chronic  nephritis  as  soon  as  the  blood-pressure  measure- 
ments are  known.  The  only  remaining  question  is  whether  the  sHght 
prostatic  enlargement  felt  by  rectum  has  anything  to  do  with  his 
frequency.     In  view  of  the  results  of  cystoscopy,  I  doubt  it. 

Tabes  was  seriously  considered  after  the  condition  of  the  bladder 
and  pupils  had  led  us  to  question  his  wife  more  closely.  The  mental 
condition  which  she  reports  and  the  pains  in  the  legs  are  significant, 
even  though  the  knee-jerks  are  normal.  The  negative  Wassermann 
reaction  should  not  lead  us  to  exclude  tabes. 

If  he  has  had  syphilis  affecting  his  spinal  cord,  it  is  quite  possible 
that  his  renal  lesion  has  a  similar  origin. 

Outcome. — During  the  earher  part  of  his  stay  in  the  hospital 
he  occasionally  had  incontinence,  but  this  was  controlled  by 
tincture  of  hyoscyamus,  lo  minims,  three  times  a  day.  Each  time 
this  drug  was  omitted  the  incontinence  returned,  disappearing  again 
when  the  drug  was  resumed.  April  loth  the  patient  had  a  sudden 
attack  of  vomiting,  without  known  cause.  The  attack  did  not 
recur.  The  renal  functions  were  tested  by  an  injection  of  phthalein; 
8  per  cent,  were  excreted  the  first  hour,  9  per  cent,  in  the  second. 
He  left  the  hospital  April  15th,  and  died  September  i,  191 2. 

Case  227 

An  engineer  of  forty  entered  the  hospital  May  25,  191 1.  There  is 
nothing  worthy  of  note  about  the  patient's  family  history  or  about  his 
past  history  until  three  weeks  ago,  when  he  had  a  shaking  chill,  accom- 
panied by  frequent  and  painful  micturition,  with  a  Httle  blood  at  the 
end.  These  symptoms  have  continued  since,  micturition  coming 
every  half-hour  and  being  very  painful.      The  urine  is  cloudy,  fairly 


FREQUENT   MICTURITION   AND   POLYURIA 


523 


abundant.  Nevertheless,  the  patient  has  worked  until  to-day,  be- 
cause he  could  not  find  a  substitute  as  engineer  at  the  Children's 
Hospital.  He  is  always  thirsty,  because,  he  believes,  of  his  work  in 
the  boiler-room.  Has  no  abnormal  appetite.  During  the  past  six 
months  he  thinks  he  has  lost  10  pounds  in  weight  and  some  strength. 

Physical  examination  shows  a  well-nourished,  powerful  man, 
without  visceral  lesions.  The  reflexes  and  pupils  are  negative. 
Rectal  examination  shows  a  soft,  enlarged,  symmetric  prostate. 
Good  x-ray  plates  of  both  kidneys  and  bladder  show  nothing  ab- 
normal. Cystoscopy  by  Dr. 
Hugh  Cabot  shows  a  normal 
bladder  capacity.  The  trigo- 
num,  the  internal  urethral  ori- 
fice, and  the  fundus  of  the 
bladder  show  evidence  of 
chronic  cystitis,  suggesting  tu- 
berculosis. The  ureteral  ori- 
fices apparently  normal.  Urine 
from  the  right  side  seems  to  be 
slightly  turbid,  that  from  the 
left  normal.  Cultures  from 
the  right  ureter  show  moderate 
growth  of  colon-like  bacilH; 
that  from  the  left  shows  the 
same  thing.  Specimens  in- 
jected into  a  guinea-pig  yield 
no  information  of  value.  The 
sediment  of  the  urine  from  the 
right  ureter  and  from  the  left 
show     essentially     the     same 

thing.  Both  contain  hyaline  and  granular  casts  and  leukocytes.  A 
functional  test  of  the  kidneys  with  phthalein  shows  normal  capacity. 

The  dysuria  following  cystoscopy  is  relieved  by  5  minims  of 
sandalwood  oil,  three  times  a  day.  The  amount  of  urine  passed, 
under  advice  to  "drink  plenty  of  water,"  is  shown  in  Fig.  194. 
Strangely  enough,  the  specific  gravity  of  the  urine  varies  Httle  from 
loio;  the  sediment  always  shows  considerable  pus.  The  blood  is 
normal.     Blood-pressure,  130  mm.  Hg. 

Discussion.— Without  cystoscopy  we  should  be  utterly  at  sea  in 
a  case  of  this  kind.  We  should  know  that  he  had  some  sort  of  an 
infection,  probably  involving  his  urinary  tract.     Beyond  that  we 


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524 


DIFFERENTIAL  DIAGNOSIS 


should  be  in  the  dark.  With  the  cultivation  of  colon  bacilli  from 
the  urine  of  each  kidney  we  may  conclude  that  operative  interfer- 
ence is  out  of  the  question.  Whatever  infection  he  has  in  the  kidney 
or  bladder  he  must  conquer  by  his  own  vital  forces  with  whatever 
non-surgical  help  we  can  give  him. 

The  negative  results  of  animal  inoculation  are  reassuring  as  to 
prognosis.  If  there  were  an  extensive  pyonephrosis  or  pyelonephritis, 
we  should  probably  be  able  to  feel  one  or  the  other  kidney,  and  the 
patient  would  probably  have  been  unable  to  work  as  he  did  up  to  the 
time  of  entering  the  hospital. 

Outcome. — The  patient  left  the  hospital  on  April  ii,  191 1,  in 
fair  condition.  November  25,  1912,  the  patient  reported  himself  in 
excellent  condition  and  at  work.  He  is  still  taking  the  capsules  of 
sandalwood  oil.  He  drinks  a  great  deal  of  water  and  sweats  pro- 
fusely. The  urine  at  this  time  was  68  ounces  in  amount,  showing  no 
turbidity,  no  albumin,  sugar,  or  pus.     The  specific  gravity  was  1008. 

Case  228 

A  schoolboy  of  fourteen  entered  the  hospital  February  14,  1912. 
His  family  history  is  negative.  Two  and  a  half  years  ago  the  patient 
noticed  a  swelling  in  his  left  neck;  it  lasted  three  weeks,  and  went  down 
without  treatment.  He  believed  it  to  be  due  to  a  bad  tooth.  Other- 
wise he  has  been  well  and  strong,  though  he  has  worn  glasses  for  seven 
years. 

December  i,  1911,  two  and  a  half  months  ago,  he  developed  "ery- 
sipelas" of  the  right  foot,  the  part  being  painful,  hot,  and  red.  This 
lasted  seven  weeks  before  the  foot  was  finally  healed,  the  doctor  having 
tried  various  liniments  and  plasters  as  well  as  internal  medicine  in 
the  meantime.     There  was  fever  with  this  attack,  but  no  chills. 

After  the  foot  was  better,  three  weeks  ago,  he  began  to  pass  small 
amounts  of  urine  every  ten  minutes.  This  frequency  has  gradually 
decreased,  until  now  he  passes  urine  about  ten  times  in  the  day  and 
four  or  five  at  night.  He  often  has  the  desire,  yet  cannot  pass  urine 
without  considerable  forcing.  At  the  onset  of  this  frequency  there  was 
pain  and  burning  as  well,  symptoms  which  now  occur  only  at  the  end 
of  micturition,  when  blood  is  also  occasionally  seen. 

Physical  examination  shows  large  red  ragged  tonsils.  Chest  and 
abdomen  negative.  Systolic  blood-pressure,  120.  The  right  tarsus, 
is  sHghtly  hot,  red,  and  tender,  and  a  little  larger  than  the  other  side. 
The  motions  of  the  ankle  and  toes  are  free  and  pamless.  Reflexes 
are  normal.     Blood  normal.     The  urine  averages  25  ounces  in  twenty- 


FREQUENT  MICTURITION   AND   POLYURIA  525 

four  hours,  with  a  specific  gravity  of  1020  and  a  trace  of  albumin, 
probably  accounted  for  by  a  considerable  amount  of  pus  and  blood  in 
the  sediment.  No  casts.  X-rays  of  the  renal  regions  were  negative 
for  tuberculosis  or  stone  anywhere  in  the  urinary  tract.  The  bones 
of  the  right  foot  showed  slight  atrophy  and  a  moderate  periostitis  of 
the  OS  calcis.  Cystoscopy  by  Dr.  Hugh  Cabot  showed  what  he  con- 
sidered bladder  tuberculosis;  20  minims  of  urinary  sediment  were 
injected  into  a  guinea-pig  February  15th.  The  pig  was  found  dead 
March  21,  191 2,  but  the  autopsy  was  negative.  A  culture  from  the 
urine  at  the  same  date,  February  15th,  showed  no  growth. 

The  x-rays  of  the  foot  were  not  considered  characteristic  of  tuber- 
culosis, yet  this  disease  could  not  be  excluded.  Hygenic  treatment 
was  thought  to  be  the  most  important  measure,  hence  the  boy  was 
discharged  on  the  24th  of  February. 

Discussion. — The  results  of  inoculation  in  this  case  are  not  con- 
clusive. The  pig  may  have  died  of  some  intercurrent  infection  before 
the  tuberculosis  had  time  to  develop.  Only  by  a  knowledge  of  the 
later  course  of  this  patient's  S5niiptoms  can  we  be  sure  what  the  nature 
of  the  bladder  trouble  was.  A  "primary  cystitis"  is  always  a  doubtful 
and  unsatisfactory  diagnosis,  yet  nothing  much  better  than  that  is 
possible  in  this  case.  The  disease  in  the  foot  and  in  the  neck  may  have 
been  tuberculous,  but  we  have  no  proof  of  it.  This  is  the  sort  of  case 
in  which  only  time  can  make  good  the  deficiencies  in  our  diagnosis. 

Outcome. — ^A  year  later  he  reported  that  since  March,  191 2,  he 
had  been  perfectly  well,  save  for  an  attack  of  "malaria"  in  the  summer. 

Case  229 

A  housewife  of  forty  entered  the  hospital  April  15,  191 2.  Her 
family  history  and  past  history  were  not  remarkable.  For  three 
months  she  has  had  frequent  and  burning  micturition,  and  noticed  a 
white  sediment  in  her  highly  colored  urine.  She  has  grown  pale  and 
short  of  breath,  but  until  ten  days  ago  had  no  pain ;  then  she  began  to 
suffer  in  both  sides  of  her  chest,  high  up,  and  in  her  shoulders,  especially 
the  right.  The  pain  is  not  constant,  but  leaves  a  steady  soreness  and 
is  worse  when  she  breathes.  It  is  sufficient  to  confine  her  to  bed. 
There  are  no  suggestive  symptoms  except  poor  appetite.  Four 
months  ago  she  weighed  115  pounds,  with  clothes;  now,  96  poimds, 
without  clothes. 

Physical  examination  showed  obvious  loss  of  weight.  Veins  of 
the  neck  prominent.  Skin  pale  yellow,  but  without  jaundice  in  the 
sclerae.     No  substernal  dulness.    Physical  examination  was  negative. 


526 


DIFFERENTIAL  DIAGNOSIS 


Fig.  195. — Abdominal  mass  found  in  Case  229. 


Fig.  196. — Chest  signs  in  Case  229. 


except  as  shown  in  Figs.  195,  196.     The  urine  averaged  40  ounces 
in  twenty-four  hours,  with  a  specific  gravity  from   1004  to   1006. 


FREQUENT  MICTURITION   AND   POLYURIA 


527 


Pus  was  always  present  in  large  amounts,  and  there  were  also  a  good 
many  red  blood  cells.  Cystoscopy  by  Dr.  Hugh  Cabot,  April  17th, 
showed  a  normal  bladder  and  ureteral  orifices.  Both  ureters  were 
catheterized  and  both  contained  cloudy,  foul  urine.  Bilateral  infec- 
tion of  the  kidney,  probably  not  tuberculous  and  not  demanding 
operation,  was  the  diagnosis.  On  the  19th  of  April  the  same  con- 
sultant found  the  urine  from  both  kidneys  looking  better  and  washed 
the  renal  pelvis  on  each  side.  Cultures  from  each  kidney  showed 
nothing  distinctive,  and  a  blood-culture 
was  also  negative.  The  course  of  the 
anemia  is  shown  in  Fig.  197.  The  stained 
smear  showed  always  a  marked  sec- 
ondary anemia  with  a  moderate  leu- 
kocytosis. 

On  the  25'th  the  patient  was  examined 
in  a  hot  bath  and  showed  a  large  non- 
tender  tumor,  palpable  bimanually,  in 
the  position  shown  in  Fig.  195.  May 
3d  the  patient  was  up  and  felt  much 
better.  The  precordial  pain,  which  was 
the  most  distressing  symptom  at  en- 
trance, had  entirely  disappeared.  The 
urine  was  reported  improved,  but  the 
anemia  was  worse,  and  she  was  dis- 
charged on  the  3d  of  May. 

Discussion. — From  the  history  of 
whitish  urine,  with  pallor  and  the  loss 
of  20  pounds'  weight  during  the  first 
three  months  of  pregnancy,  a  septic  or 
tuberculous  process  in  the  kidney  comes 
at  once  to  mind  as  the  most  probable 
explanation  of  the  patient's  frequency. 
The  condition  of  the  blood  is  puzzling, 
and,  taken  by  itself,  would  strongly  sug- 
gest pernicious  anemia,  though  the  slight 
increase  of  leukocytes  would  be  atypical 
under  such  a  diagnosis.     I  looked  at  the 

blood  myself  on  the  i6th  of  April  and  called  it  a  secondary  anemia, 
on  account  of  the  notable  leukocytosis,  although  I  could  find  no 
achromia.  There  were  moderate  variations  in  the  size  and  shape  of  the 
red  cells,  no  stippling,  no  blasts.     Such  an  anemia  is  more  often  seen 


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528  DIFFERENTIAL  DIAGNOSIS 

in  septicemia  than  in  tuberculosis.  As  a  result  of  cystoscopy  there  was 
a  demonstration  of  infection  in  both  kidneys.  Operation  was,  of 
course,  impossible.  It  is  to  be  regretted  that  no  animal  inoculation 
was  made. 

At  the  time  she  left  the  hospital  we  expected  a  steady  progress 
of  the  disease  to  a  fatal  termination. 

Outcome. — November  23,  191 2,  her  husband  reported  that  she 
"got  along  line  after  leaving  the  hospital"  until  the  last  week  in  Au- 
gust, when  diarrhea  and  vomiting  began  (after  a  vacation  trip)  and 
lasted  until  her  death,  September  6,  191 2. 

Case  230 

A  teamster  of  forty-one  entered  the  hospital  April  22,  191 2. 
The  patient  is  moderately  alcoholic,  but  otherwise  shows  nothing  of 
importance  in  past  history  or  family  history.  Eight  weeks  ago 
micturition  became  frequent  and  caused  burning  pain,  especially 
in  the  latter  portion.  Seven  weeks  ago  he  noticed  that  the  urine  at 
the  end  of  micturition  was  bloody.  At  the  same  time  the  left  ankle, 
hip,  and  knee  became  so  sore  and  painful  on  motion  that  he  stayed 
in  bed  for  a  week.  Six  weeks  ago  he  had  severe  colicky  pain  in  the 
right  lumbar  region  and  flank,  radiating  down  the  ureter.  This 
pain  lasted  half  an  hour  and  has  not  recurred.  There  was  no  change 
in  the  urine  at  the  time.  Since  then  he  has  been  fairly  well  save 
for  the  local  urinary  symptoms,  but  he  has  noticed  that  his  urine  is 
cloudy  and  has  a  white  sediment. 

Two  days  ago  his  right  knee  suddenly  swelled  and  became  red, 
hot,  and  tender,  so  that  he  walks  on  crutches.  Despite  these  troubles 
his  appetite  has  remained  fair  and  he  has  kept  his  usual  weight, 
145  pounds. 

Physical  examination  shows  in  the  precordia  a  soft  systolic  mur- 
mur, present  only  during  inspiration.  The  aortic  second  sound  is 
more  intense  than  the  pulmonic  second;  otherwise  visceral  exam- 
ination is  negative.  The  right  knee  is  swollen,  hot,  red,  and  tender. 
The  patella  floats  and  there  is  considerable  thickening  about  the 
joint.  On  the  dorsum  of  the  right  foot  there  is  a  tender  spot.  A 
smear  of  pus  obtained  from  the  prostate  shows  a  few  polynuclear 
leukocytes  and  a  rare  diplococcus,  negative  to  Gram.  By  rectum  the 
prostate  is  tender,  uneven  in  consistency,  and  contained  an  excessive, 
shghtly  purulent  secretion,  believed  to  be  due  to  gonorrheal  prosta- 
titis. The  treatment  advised  is  irrigation  and  massage  of  the  pros- 
tate.    The  gonococcus  fixation  test  is  moderately  positive;  the  Was- 


FREQUENT  MICTURITION   AND   POLYURIA  529 

sermann,  negative;  a;-ray,  No.  20,646,  shows  evidence  only  of  an  in- 
fectious arthritis  in  the  right  knee. 

Gonococcus  vaccines,  50,000,000  every  four  days,  were  given  by 
Dr.  Steele.  During  four  weeks  in  the  ward  the  patient  ran  a  slight 
irregular  fever,  now  and  again,  never  exceeding  100°  F.  The  urine 
averaged  60  ounces  in  twenty-four  hours,  with  a  specific  gravity  of 
loio,  and  during  the  first  few  days  a  slight  trace  of  albumin.  The 
sediment  always  contained  pus,  though  the  amount  became  much 
less  during  the  later  weeks  of  treatment. 

Discussion. — When  the  joints  are  effected  simultaneously  with 
bladder  symptoms  of  this  type  a  general  infection  is  naturally  our 
first  thought.  The  fact  that  he  has  had  a  pain  along  the  ureter  leads 
us  to  imagine  that  the  trouble  may  have  extended  up  to  the  pelvis  of 
the  kidney,  wherein  a  blocking  with  pus  might  cause  pain.  The 
condition  of  •  the  right  knee  on  physical  examination  is  that  most 
often  seen  in  gonorrheal  arthritis,  and  the  blood-test  goes  to  confirm 
this,  likewise  the  rectal  examination.  Presumably  he  had  a  gonor- 
rheal prostatitis  and  pyelitis  as  well. 

Outcome. — By  May  ist  the  right  knee  was  almost  normal,  but  the 
left  knee  was  very  large  and  showed  practically  the  condition  present 
in  the  right  at  entrance.  This  condition  in  the  knees  progressed 
and  improved,  from  day  to  day,  in  an  irregular  way  until  the  15th, 
when  both  knees  seemed  to  have  cleared  up  and  the  patient  was 
allowed  to  go  home. 

Case  231 

A  housewife  of  sixty-six  entered  the  hospital  July  18,  191 2.  Her 
family  history  was  negative  and  past  history  not  remarkable. 

About  a  year  ago  she  began  to  have  frequent  and  burning  mic- 
turition. The  urine  looked  a  little  darker  than  usual,  but  was  never 
bloody.  The  quantity  was  not  increased  and  there  was  no  inconti- 
nence, but  at  times  the  urine  was  passed  every  half  hour,  night  and 
day.  With  slight  periods  of  improvement  this  has  persisted  ever 
since,  though  she  has  kept  about  and  worked  until  six  weeks  ago. 
At  that  time  she  began  to  have  severe  pain  in  the  small  of  her  back 
and  in  one  or  the  other  hip.  The  pain  was  increased  by  motion,  and 
was  similar  to  the  attacks  of  "lumbago,"  which  she  has  often  had 
before.  This  pain,  however,  disappeared  a  month  ago  and  has  not 
recurred. 

For  six  weeks  she  has  been  in  bed  most  of  the  time  and  has  lost 
her  appetite.     She  is  constipated  and  is  much  troubled  with  gas 

Vol.  11—34 


53©  DIFFERENTIAL  DIAGNOSIS 

in  the  bowels.  For  six  months  she  has  noticed  shortness  of  breath  on 
exertion,  and  for  three  months  swelling  of  the  feet  and  ankles,  disap- 
pearing when  she  goes  to  bed.  There  has  been  no  fever,  cough,  or 
jaundice.  Her  main  complaints  are  of  the  urinary  frequency  and 
great  weakness. 

Physical  examination  shows  the  patient  moderately  emaciated. 
The  heart  is  negative  except  for  a  soft  systolic  murmur  at  the  base, 
and  there  is  an  accentuation  of  the  pulmonic  second  sound.  There  is 
soft  edema  of  the  lower  back  from  the  twelfth  rib  to  the  sacrum  and 
over  the  anterior  abdominal  wall.  Some  also  in  the  thighs.  Vaginal 
examination  shows  that  the  base  of  the  bladder  is  thickened  and 
firm,  forming  a  rounded  mass  several  centimeters  thick,  which  bulges 
slightly  in  the  anterior  vaginal  wall.  The  urine  averages  35  ounces 
in  twenty-four  hours,  with  a  specific  gravity  in  the  neighborhood  of 
1018.  It  contains  much  fresh  blood  and  many  masses  of  multi- 
nuclear  epithelial  cells;  no  casts  and  few  leukocytes.  Culture  from 
the  urine  showed  no  growth.  Blood  showed  red  cells,  4,700,000; 
white  cells,  10,500;  hemoglobin,  60  per  cent.  Stained  smear  gave 
evidence  of  achromia. 

Discussion. — At  tliis  patient's  age  such  bladder  symptoms  are 
probably  due  to  stone  or  malignant  disease.  Emaciation  favors 
the  latter  alternative,  and  if  her  dyspnea  and  edema  are  not  due 
to  some  separate  cause  they  would  round  out  the  diagnosis  of 
malignant  disease,  which  the  vaginal  examination  renders  prac- 
tically certain.  Tuberculosis  originating  at  her  age  is  practically 
unknown. 

Outcome. — Cystoscopy,  July  19th,  by  Dr.  Hugh  Cabot,  showed  a 
new  growth  in  the  bladder,  believed  to  be  cancer  on  account  of  the 
suggestion  of  glandular  involvement  given  by  the  edema.  No  opera- 
tion was  advised.  Accordingly,  the  patient  left  the  hospital  July 
2oth  and  died  three  days  later. 

Case  232 

An  Irish  laborer  of  seventy-nine  entered  the  hospital  July  18, 
191 1.  The  patient  says  he  has  had  pain  in  the  epigastrium  for 
twenty  years  and  that  it  has  steadily  been  growing  worse.  He  has 
no  other  gastric  symptoms  and  has  otherwise  been  well.  He  drinks 
whisky  two  or  three  times  a  day. 

For  a  year  he  has  noticed  that  his  urination  was  frequent  and 
caused  burning.  There  has  been  no  retention  and  no  incontinence, 
but  for  the  past  two  weeks  he  has  passed  urine  about  every  hour 


FREQUENT  MICTURITION   AND   POLYURIA 


531 


in  the  daytime  and  five  or  six  times  at  night.     The  urine  is  foul  and 
cloudy;  sometimes  only  a  teaspoonful  at  a  time  is  passed. 

Physical  examination  showed  tortuous,  hard,  beaded  arteries. 
The  heart's  apex  was  in  the  sixth  space,  i  cm.  outside  the  midclavic- 
ular line.  Aortic  second  was  accentuated.  A  soft  systolic  murmur 
was  localized  in  the  apex  region.  The  chest  was  barrel  shaped,  hy- 
perresonant  throughout.  The  expiration  was  prolonged,  accompanied 
by  squeaks  and  crackles.  The  bladder  was  distended,  reaching  to 
within  2  inches  of  the  umbilicus. 
There  was  right  inguinal  hernia. 
By  rectum  the  prostate  was 
moderately  enlarged,  not  tender, 
fairly  firm  in  consistency;  22 
ounces  of  urine  were  drawn  by 
catheter,  alkaline  in  reaction, 
1012  in  gravity,  containing  much 
pus  and  blood.  The  twenty- 
four-hour  amount  thereafter 
averaged  50  ounces.  The  tem- 
perature as  in  Fig.  198.  The 
patient  was  put  on  constant 
drainage  and  kept  so  for  four- 
teen days.  By  the  phenolsul- 
phonephthalein  test  6  per  cent, 
was  excreted  in  the  first  hour, 
the  color  first  appearing  in 
thirty-five  minutes  the  first  time, 

later  in  fifty-five  minutes.     On  the  14th  of  August  he  developed  acute 
epididymitis  on  the  left;  by  the  17th  that  had  begun  to  subside. 

Discussion. — The  patient  clearly  has  arteriosclerosis  and  an 
enlarged  heart  with  emphysema,  but  at  present  his  trouble  is  a  dis- 
tended bladder,  presumably  due  to  prostatic  enlargement.  The 
only  question  of  interest  is  whether  or  not  he  has  cancer  of  the  pros- 
tate. Of  the  latter  condition,  the  rectal  examination  gives  no  evi- 
dence and  there  is  nowhere  else  to  look  for  any.  We  are  dealing 
in  this  case  purely  with  symptoms  of  obstruction,  not  with  pain  or 
hematuria,  such  as  are  associated  with  tuberculosis,  cancer,  or  primary 
cystitis.  The  development  of  acute  epididymitis  is  one  of  the  un- 
avoidable complications  of  constant  drainage,  in  a  certain  percentage 
of  prostatic  cases,  and  does  not  complicate  in  any  way  the  diagnosis, 
while  it  may  darken  the  outlook. 


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532  DIFFERENTIAL  DIAGNOSIS 

Outcome. — By  the  2 2d  of  August  he  was  much  better  in  his  general 
condition,  and  was  allowed  to  go  home. 

Case  233 

A  housewife  of  lifty-two  entered  the  hospital  May  12,  1908. 
For  the  past  three  or  four  months  the  patient  has  been  troubled  with 
thirst,  polyuria,  and  increasing  nocturia,  now  eight  to  ten  times;  also 
dyspnea,  which  in  the  past  two  weeks  has  amounted  to  orthopnea. 
She  has  had  occasional  attacks  of  vomiting,  has  lost  considerable  in 
weight,  and  her  eyesight  has  rapidly  been  growing  poor.  Her  head- 
ache has  also  been  a  troublesome  symptom  of  late.  Previously  to  this 
she  has  always  been  well,  has  had  fifteen  children,  and  three  mis- 
carriages. 

Physical  examination  showed  obesity,  pale,  dry  skin;  pupils, 
glands,  and  reflexes  negative.  The  heart's  apex  was  i  inch  outside 
the  midclavicular  line.  Right  border  dulness  f  inch  to  right  of  mid- 
sternum.  The  heart's  action  was  irregular,  with  frequent  premature 
contractions.  The  aortic  second  sound  was  markedly  accentuated, 
no  murmurs.  The  artery  walls  were  thickened.  Blood-pressure, 
240  mm.  Hg.,  systolic.  Slight  dulness  and  crackling  rales  at  both 
bases  behind.  Abdomen  negative.  Considerable  edema  of  the  legs 
and  back.  Blood  negative.  Urine,  32  ounces  in  twenty-four  hours; 
specific  gravity,  loio;  sediment  negative.  She  did  not  improve  during 
her  week  in  the  hospital,  and  was  taken  home  by  her  friends  on  the 
19th  of  May.  She  returned  on  the  20th  of  June.  She  has  had  attacks 
of  vomiting  four  or  five  times  a  day  since  she  left.  She  has  been  in 
bed;  had  no  appetite  and  some  dyspnea,  but  no  orthopnea.  The 
heart's  apex  was  at  this  time  in  the  anterior  axillary  line,  right  border 
of  dulness  i^  inches  to  right  of  midsternum.  Blood-pressure,  235 
mm.  Hg.  In  the  left  lung  there  was  dulness,  absent  breathing,  and 
faint  nasal  voice  sounds,  with  crackling  rales  below  the  lower  angle  of 
the  left  scapula.  Abdomen  negative.  SHght  edema  of  the  legs.  At 
this  time  she  seemed  a  good  deal  better  than  when  she  left  the  hospital 
before,  and  improved  still  further  during  her  ten  days'  stay,  though 
she  still  vomited  each  morning.  The  condition  of  the  urine  was  as 
before,  although  an  occasional  hyaline  and  granular  cast  was  found. 
She  went  home  on  the  30th  of  June. 

Discussion. — When  a  patient  consults  a  physician  primarily  for 
thirst  and  polyuria,  the  diagnosis  is  usually  saccharine  diabetes.  The 
unusual  thing  about  this  case  is  that  the  urine  contained  no  sugar. 

As  soon  as  we  go  beyond  the  presenting  symptom,  we  find  dysp- 


FEEQUENT  MICTURITION   AND   POLYURIA  533 

nea,  headache,  vomiting,  poor  eyesight,  and,  above  all,  an  enormous 
degree  of  hypertension;  in  other  words,  the  complete  cHnical  picture 
of  chronic  nephritis,  which  in  this  patient  has  run  probably  its  entire 
course  up  to  this,  its  terminal  stage  of  contracted  kidney,  without 
any  symptoms  at  all.  So  it  is  with  most  cases  of  chronic  nephritis. 
They  are  entirely  symptomless  until  their  later  stages.  This  is  espe- 
cially true  of  the  arteriosclerotic  varieties  and  of  all  mixed  cases  in 
which  the  arteriosclerotic  element  predominates  over  the  glomerular 
element.  There  is  no  reasonable  doubt  of  the  diagnosis  and  no  need 
of  discussion. 

It  is  worth  mentioning,  however,  that  now  and  then  a  patient 
comes  to  us  complaining  of  dry  mouth  and  of  nothing  else,  but  pre- 
senting on  careful  study  a  picture  similar  to  that  of  this  case,  though 
less  in  degree  and  intensity.  A  good  many  such  "dry  mouth"  cases 
are  associated  with  prostatic  obstruction  and  are  regarded  by  the 
genito-urinary  surgeon  as  poor  risks.  The  dry  mouth  is  often,  but  not 
always,  an  ominous  s3rmptom.  Curiously  enough,  it  is  now  and  then 
wholly  relieved  by  chewing  dry  crackers. 

Case  234 

A  schoolboy  of  seventeen  entered  the  hospital  August  i8,  1909. 
Family  history  is  negative.  During  the  first  months  of  his  life  he 
had  convulsions,  but  since  then  has  had  nothing  of  the  kind,  though 
he  has  occasionally  been  troubled  by  "rushes  of  blood  to  the  head  and 
by  choking  sensations." 

In  June,  1909,  eight  weeks  ago,  he  first  noticed  that  he  was  passing 
a  great  deal  of  urine,  getting  up  three  or  four  times  in  the  night  to 
urinate,  and  drinking  a  great  deal  of  water.  Appetite  very  good  until 
two  weeks  ago,  since  then  poor.  He  has  been  constipated  of  late 
and  has  vomited  once  or  twice.  He  has  no  headache  and  sleeps  very 
well,  but  his  mouth  is  always  dry,  and  he  thinks  he  has  lost  a  Uttle 
weight. 

Physical  examination  shows  good  nutrition,  a  dry,  harsh  skin. 
Otherwise  negative.  The  range  in  the  amount  of  urine  is  shown  in 
Fig.  199.  Fundus  ocuU  was  normal.  The  patient  was  put  on  Folin's 
diet  and  the  amount  of  urinary  excretion,  as  compared  with  the  salt 
ingestion,  was  studied.  Later  he  was  put  on  a  diet  of  protein  without 
salt,  and  the  amount  of  urine,  together  with  the  thirst,  rapidly  de- 
creased. As  soon  as  salt  was  added  to  the  diet  the  urine  returned  to 
nearly  its  former  amount.  September  13th  a  positive  Wassermann 
reaction  was  obtained.    September  i6th  he  was  given  a  salt-free  diet 


534 


DIFFERENTIAL   DIAGNOSIS 


containing  nitrogen  and  again  the  amount  of  urine  diminished, 
though  still  remaining  considerably  above  the  normal.  In  view  of  the 
positive  Wassermann  reaction,  the  patient  was  given  mercurial  in- 
unctions and  iodid  of  potash  in  increasing  doses.  He  decided  to  go 
home  on  the  30th,  having  lost  no  weight  since  the  first  week  of  en- 
trance and  having  achieved  no  gain. 


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Fig.  199. — Urine  chart  in  Case  234. 


Discussion. — The  enormous  degree  of  frequency  and  polyuria 
which  this  boy  exhibited,  when  associated  with  a  poor  appetite  and 
known  to  be  continuous,  leaves  only  one  probable  diagnosis  in  the 
foreground,  diabetes  insipidus.  The  presence  of  a  positive  Wasser- 
mann reaction  is  no  reason  for  changing  this  diagnosis,  since  we  still  use 
the  term  "diabetes  insipidus"  to  cover  cases  with  some  organic  brain 


FREQUENT  MICTURITION  AND   POLYURIA  535 

lesion  as  well  as  those  with  unknown  pathology.  In  differential  diag- 
nosis the  main  thing  is  to  exclude  nephritis,  which  in  this  case  was 
easy,  and  to  determine  that  the  frequency  and  polyuria  are  not  of  tem- 
porary nervous  origin.  The  lapse  of  time  and  the  careful  study  of  the 
case  exclude  these  possibilities  beyond  doubt. 

We  tried  various  experiments  with  this  patient's  diet  and  showed 
that  a  salt-free  diet  would  for  a  time  reduce  his  polyuria,  but,  as  such 
a  diet  could  not  be  kept  up  for  any  length  of  time  without  great 
danger,  its  temporary  effects  were  of  no  benefit  to  the  patient. 

It  is  of  some  importance  to  note  that  antisyphilitic  treatment 
produced  no  benefit.  This  is  what  we  have  learned  that  we  must 
expect  in  many  cases  of  diabetes  insipidus,  even  when  the  Wassermann 
reaction  leads  us  to  hope  that  we  may  secure  good  therapeutic  results. 

Outcome. — The  patient  died  February  27,  1910.  During  most  of 
the  latter  months  of  his  life  he  could  eat  scarcely  anything.  He  drank 
an  enormous  amount  of  milk  and  water,  but  vomited  most  of  it  within 
half  an  hour.  After  Thanksgiving  he  was  confined  continuously  to  bed, 
and  for  three  months  before  his  death  he  took  absolutely  no  solid  food 
and  lived  wholly  on  orangeade  and  moxie.  He  suffered  no  pain,  but 
during  these  bed-ridden  months  there  were  troublesome  cramps  in  his 
arms  and  legs,  and  finally  contractures  developed  in  all  four  ex- 
tremities. There  was  no  fever  or  cough,  no  headache,  no  trouble  with 
the  movements  of  his  bowels.  Toward  the  end  of  life  he  was  not 
drowsy,  but  emaciated  to  skin  and  bone,  the  enormous  polyuria 
continuing  up  to  the  very  end,  although  he  was  too  weak  to  pass 
urine  spontaneously  and  had  to  be  catheterized.  There  was  much 
itching  of  the  skin. 

Case  235 

A  schoolboy  of  fourteen  entered  the  hospital  February  14,  1910. 
He  has  always  been  well.  Good  family  history.  Eighteen  days  ago 
he  ate  a  hearty  dinner,  with  a  good  deal  of  ice-cream,  and  drank 
much  water.  During  the  next  twenty-four  hours  he  passed  more 
urine  than  usual,  and  after  that  seemed  to  be  all  right,  but  a  week  later 
he  had  another  attack  of  polyuria,  and  since  then  has  passed  over 
2  quarts,  sometimes  3  quarts,  daily.  Four  days  ago  sugar  was  dis- 
covered in  the  urine.  His  appetite  has  been  very  good  all  winter, 
but  not  until  the  last  two  weeks  did  he  notice  any  thirst  or  drjmess  in 
the  mouth,  and  not  until  that  time  did  he  lose  any  weight. 

On  physical  examination  he  is  well  developed,  dry  skin,  viscera 
and  reflexes  normal.    Urine,  40  gm.  of  sugar  a  day,  quickly  jdelding 


536  DIFFERENTIAL  DIAGNOSIS 

to  strict  diet.  The  boy  stayed  twenty  days  in  the  hospital,  and  during 
the  last  live  days  had  no  sugar  in  the  urine.  Acidosis  was  very  sHght, 
and  the  boy  held  his  weight  at  118  pounds  without  considerable 
change. 

Discussion. — The  sudden  onset  of  symptoms  is  of  some  interest. 
The  diagnosis  could  never  have  been  in  doubt,  provided  the  urine 
were  examined.  It  is  notable  that  he  never  suffered  from  thirst  or  dry 
mouth  and  that  for  a  considerable  period  he  maintained  his  weight, 
although  no  changes  were  made  in  his  diet.  The  prognosis  for  such 
a  case  is  poor,  even  when  response  to  treatment  is  excellent,  as  during 
his  hospital  stay.     Very  few  such  cases  live  more  than  a  year  or  two. 

Outcome. — He  went  home  on  the  2d  of  March,  19 10,  and  died  in 
coma,  March  14,  1911. 

Case  236 

A  carpenter  of  thirty-eight  entered  the  hospital  March  31,  1910. 
The  patient's  family  history  and  past  history  are  excellent.  He  used 
to  drink  heavily  until  two  years  ago. 

About  Christmas-time  he  began  to  notice  that  he  passed  large 
amounts  of  urine.  He  was  much  worried  by  the  statement  of  his 
doctor  that  he  had  tuberculosis.  Since  last  Christmas  he  has  done  no 
work,  and  for  the  past  six  weeks  can  scarcely  go  up  stairs  because  of 
weakness  and  shortness  of  breath.  His  appetite  is  good  and  he  has 
no  cough,  but  there  is  some  palpitation  and  some  swelling  of  the  legs. 
His  legs  seem  much  weaker  than  any  other  portion  of  his  body.  He 
has  no  pain  anywhere. 

Physical  examination  showed  fair  nutrition  and  marked  pallor. 
About  the  knees  and  elbows  were  many  small  flattened  red  papules, 
covered  with  scales.  His  teeth  were  poor  and  many  missing.  Chest 
and  abdomen  were  negative.  Reflexes  and  pupils  normal.  Blood 
showed  red  cells  2,144,000;  white,  9500;  hemoglobin,  50  per  cent. 
In  the  stained  specimen  were  marked  achromia,  slight  variations  in 
size  and  shape  of  the  red  cells.  Differential  count  normal.  The 
yellowish  tint  of  the  skin  was  such  as  to  suggest  pernicious  anemia, 
but  the  blood-picture  was  that  of  secondary  anemia  (Fig.  200). 
There  was  a  positive  guaiac  reaction  in  the  stools  at  entrance,  but 
this  was  found  to  be  due  to  piles,  for  which  operation  was  advised 
by  Dr.  Mixter. 

The  urine  contained  sugar  in  amount  varying  between  40  and 
60  gm.  a  day  on  a  strict  diabetic  diet  with  200  gm.  of  bread,  and 
on  all  the  subsequent  reductions  in  the  amount  of  bread  no  change 


FREQUENT  MICTURITION  AND   POLYURIA 


537 


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538 


DIFFERENTIAL   DIAGNOSIS 


occurred,  though  during  the  last  week  of  his  stay  in  the  hospital  the 
diet  contained  no  carbohydrates.     He  went  home  on  the  nth. 

The  patient  entered  the  second  time  on  the  17th  of  January,  191 1, 
stating  that  since  his  discharge  he  had  been  much  the  same,  gaining 
weight  when  he  loafed  and  losing  it  when  he  worked.  He  has  not 
stuck  to  his  diet  (Fig.  201). 

Three  weeks  ago  he  got  what  was  called  "pneumonia,"  beginning 
with  a  heavy  cold,  followed  by  chills  and  fever,  with  pain  in  the  left 
lower  chest  and  cough,  with  scanty  whitish  sputum.  A  little  cough  per- 
sists.   At  this  time  physical  examination  showed  slight  dulness  and 


occa&\ov\aV 


brcaih\Y\o, 


Fig.  202. — Chest  signs  in  Case  236. 


occasional  moist  rales  at  the  left  base  (Fig.  202).  Just  inside  the 
angle  of  the  left  scapula  was  a  patch  of  bronchovesicular  breathing  and 
increased  whisper.  Otherwise  physical  examination  was  unchanged, 
except  for  his  red  cells,  which  had  risen  to  3,200,000;  white  cells, 
19,000.  Hemoglobin  remained  at  50  per  cent.  The  stained  smear 
still  showed  marked  achromia  with  a  polynuclear  leukocytosis.  The 
amount  of  sugar  was  considerably  greater  than  on  previous  examina- 
tion. Under  strict  diet  it  was  gradually  brought  down  to  about 
40  gm.  a  day.  At  this  time,  as  on  the  previous  occasion,  he  had 
considerable  diarrhea. 


FREQUENT  MICTURITION   AND   POLYURIA 


539 


After  leaving  the  hospital  the  last  time  he  adopted  a  diet  of  his 
own,  containing  as  much  milk  and  cereals  as  he  Uked  and  two  shces 
of  bread.  On  this  diet  he  worked  at  carpentering  two  or  three  days 
a  week  and  felt  well  and  fairly  strong  until  a  week  ago,  though  he 
has  had  several  spells,  lasting  a  week  or  two,  when  he  would  be  "all 
done  up"  and  feel  very  weak  and  drowsy. 

A  week  ago  he  caught  cold,  felt  tired  and  miserable.  Four  days 
ago  he  was  feverish  and  chilly  at  night  and  felt  sore  all  over.  The 
next  morning  he  began  to  cough  and  felt  pain  in  the  left  lower  chest. 
These  symptoms  have  continued  since,  though  his  appetite  has 
been  good.  His  weight  has  gradually 
fallen  since  spring  from  145  pounds  at 
that  time  to  133  pounds  now. 

Physical  examination  showed  essenti- 
ally the  signs  given  in  Fig.  202.  X-ray, 
according  to  Dr.  Walter  J.  Dodd,  showed 
a  less  local  and  more  diffuse  process  than 
would  be  expected  from  tuberculosis. 
The  diaphragm  was  found  to  move  poorly 
on  the  left.  September  27th  the  chest 
showed  all  the  signs  of  solidification  in 
the  left  middle  back,  with  some  crackles 
at  both  bases  and  an  occasional  friction 
sound. 

Discussion. — The  remarkable  feature 
of  this  case  is  the  anemia.  Most  diabet- 
ics have  no  considerable  anemia,  and  the 
opposite  condition,  a  concentration  of 
the  blood  with  polycythemia  in  the  ujiit 

obtainable,  is  the  rule.  It  does  not  seem  to  me  that  the  patient's 
hemorrhoids  are  likely  to  be  the  explanation  of  his  anemia,  for  imder 
observation  it  was  proved  that  he  lost  scarcely  any  blood,  and  the  rise 
in  his  red  count  under  treatment  was  not  at  all  marked. 

Another  feature  of  interest  is  the  cause  of  his  dyspnea.  Although 
his  local  physician  told  him  three  months  before  we  saw  him  that  he 
had  tuberculosis,  we  could  not  find  the  evidence  of  it  at  the  time  of 
his  first  entrance  to  the  hospital.  Later,  we  found  some  dubious  signs 
which  might  be  interpreted  as  tuberculosis  or  as  bronchopneumonia. 
At  no  time  was  there  any  considerable  cough  or  sputa.  Dyspnea  was 
his  only  pulmonary  symptom. 

All  this  is  quite  in  accord  with  the  fact  that  at  postmortem  many 


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Fig.  203. — Chart  of  Case  236. 


540  DIFFERENTIAL  DIAGNOSIS 

cases  are  proved  to  have  a  complicating  tuberculosis  unrecognized 
during  life.  We  should  learn  to  be  prepared  for  the  fact  that  tubercu- 
losis complicating  diabetes  gives  a  very  different  and  a  much  less  dis- 
tinctive cHnical  picture  and  physical  signs  when  compared  with  the  or- 
dinary non-diabetic  consumptive.  Cough  and  sputum  are  often  absent, 
even  when  the  pulmonary  lesions  are  extensive.  Rales  are  less  con- 
stant and  less  numerous.  In  several  cases  that  I  have  watched  there 
has  been  none  of  the  usual  march  of  the  disease  from  the  apices  down- 
ward. The  tuberculosis  appeared  in  patches  throughout  a  whole  lung, 
as  marked  at  the  base  as  above. 

Outcome. — The  patient  remained  a  week  in  the  hospital  at  this 
time,  gained  no  weight,  and  went  home  on  the  27  th  at  his  own  re- 
quest (Fig.  203). 


CHAPTER  XII 

FAINTING 

Apparently,  fashions  have  changed  since  Walter  Scott's  time. 
Ladies  do  not  faint  as  they  used  to,  and  I  do  not  suppose  we  shall 
ever  know  exactly  what  was  the  pathologic  condition  of  Scott's  heroines 
and  the  other  ladies  of  that  time.  At  any  rate,  it  must  be  clear  that 
fainting  is  much  rarer  than  we  used  to  suppose  it  to  be. 

But  beyond  the  narrowing  scope  of  the  term  in  its  popular  use, 
and  its  availability  in  difficult  situations,  there  is  certainly  a  medical 
narrowing  of  its  use  as  well.  Many  attacks  of  unconsciousness  which 
used  to  be  called  fainting  would  now  receive  some  more  significant 
and  more  serious  name.  The  typical  fainting  attack,  as  we  know  it  at 
the  present  time,  is  such  as  comes  on  in  persons  predisposed  to  such 
attacks  when  they  are  confined  in  a  poorly  ventilated  room,  or  when 
they  are  compelled  to  witness  some  disaster  involving  bloodshed. 
Just  what  happens  in  these  cases  we  do  not  know.  It  is  customary  to 
suppose  that  the  individual  loses  consciousness  because  of  cerebral 
anemia.  The  face  is  pale,  the  extremities  cool,  pulse  feeble,  and 
it  seems  as  if  the  heart  was  doing  very  little  work.  But  exactly  why 
cerebral  anemia,  when  produced  in  chronic  diseases,  such  as  pernicious 
anemia,  so  seldom  leads  to  fainting  is  not  at  all  clear.  Perhaps  chronic 
anemia  with  its  slow  onset  gives  the  brain  opportunity  to  accommo- 
date itself  in  some  way. 

However  this  may  be,  it  is  certainly  true  that  we  are  much  more 
cautious  than  we  used  to  be,  when  we  decide  to  call  a  given  attack  of 
unconsciousness  a  fainting  fit.  Many  such  attacks  turn  out  to  be 
epilepsy  in  its  minor  form.  Others  manifest  cerebral  arteriosclerosis 
or  a  lesion  of  His'  bundle.  The  diagnosis,  then,  is  only  to  be  made 
after  every  effort  to  find  organic  disease  has  failed. 

It  is  important  to  realize  that  just  before  the  end  of  a  fainting  fit 
the  patient  not  infrequently  has  a  brief,  generalized  convulsion.  One 
need  not  give  up  the  diagnosis  of  fainting  or  swing  over  to  epilepsy 
merely  because  of  such  a  convulsion.  I  have  repeatedly  observed  it 
in  attacks  which  deserved  to  be  called  fainting,  if  the  term  is  ever  to 
be  used  at  all. 

541 


542  DIFFERENTL'^L  DIAGNOISS 

Another  point  not  always  realized  in  relation  to  genuine  fainting 
fits  is  that  the  patient  may  altogether  stop  breathing  for  a  period 
long  enough  to  cause  considerable  alarm,  even  to  the  physician. 
Such  a  period  of  aphonia  would  doubtless  end  itself  before  any  serious 
results  occurred,  but  it  may  be  brought  to  an  end  promptly  by  the 
use  of  artificial  respiration. 

In  a  general  way,  such  attacks  are  unimportant  in  the  young  and 
serious  in  the  old.  The  exception  to  this  statement  is  found  in  the 
possibility  that  a  petit  mal — in  other  words,  a  minor  epileptic  attack — 
may  be  mistaken  for  a  faint. 

Hysteric  coma  differs  from  fainting  in  that  it  has  less  definite 
relation  to  bad  air  and  sudden  fright.  It  is  more  under  the  control 
of  the  will,  and  usually  lasts  much  longer  than  a  fainting  fit.  The 
latter  is  usually  over  in  a  minute  or  two,  the  former  lasts  for  hours. 
Fainting  fits  have  always  marked  circulatory  phenomena  suggesting 
cerebral  anemia,  while  in  hysteric  attacks  such  evidence  is  wanting. 

Aside  from  the  tendency  to  bad  air  and  mental  shock  to  cause 
fainting,  it  is  well  recognized  that  such  attacks  are  more  prone  to  occur 
in  certain  predisposed  individuals  or  families. 

Many  such  individuals  outgrow  the  tendency  to  faint  as  they 
advance  in  years.  Beyond  this,  it  may  be  stated  that  all  diseases 
which  weaken  the  patient  profoundly  make  him  more  likely  to  faint. 

Fainting  and  vertigo  are  symptoms  often  closely  associated. 
Almost  all  of  the  causes  of  vertigo  are  also,  on  occasions,  causes  of 
fainting  and  vice  versa. 

Case  237 

A  man  of  forty-two,  occupied  in  making  white  lead,  entered  the 
hospital  December  8,  1900.  The  patient  had  never  been  sick  before, 
except  for  "brain  fever,"  which  he  had  eighteen  years  ago  in  St.  John's 
Hospital,  Newfoundland.  He  was  in  bed  seven  weeks  and  dehrious 
seven  days. 

Ten  years  ago  an  empty  water  barrei  fell  35  feet  and  struck  him 
in  the  forehead.  He  was  unconscious  several  minutes,  in  bed  three 
days,  out  of  work  two  weeks.  Since  that  time  he  has  had  a  sense  of 
burning  above  the  left  eye  whenever  he  thinks  about  it.  He  uses 
about  I  pint  of  whisky  in  five  weeks  and  ten  cents'  worth  of  tobacco  a 
week. 

He  now  comes  to  the  hospital  on  account  of  fainting  spells,  which 
began  eight  weeks  ago  with  dizziness  and  nausea  which  three  or  four 
times  have  led  to  vomiting,  brought  on,  apparently,  by  suddenly 


FAINTING 


543 


lifting  his  head  from  the  pillow  or  turning  quickly.  He  never  has 
trouble  while  lying  down  or  standing  quietly.  Three  weeks  ago,  as 
he  started  to  turn  over  in  bed,  he  grew  so  dizzy  that  he  fell  over  the 
side  of  the  bed  on  to  the  floor.  He  was  unconscious  a  few  minutes, 
vomited  several  times,  and  had  some  stomach  trouble  for  the  next 
week.  He  has  had  four  similar  attacks,  each  one  milder  than  the  last. 
For  four  years  he  has  had  occasional  spells  of  abdominal  pain,  lasting 
an  hour  or  two,  attributed  by  him  to  constipation.  Bowels  move 
every  day  or  two.  He  has  had  nosebleed  almost  every  day  for  two 
weeks.  For  two  months  his  head  has  felt  heavy,  as  if  it  were  an  effort 
to  hold  it  up  and  prevent  its  dropping  on  to  his  left  shoulder. 


Fig.  204. — Area  of  partial  anesthesia  in  Case  237. 


Physical  examination  shows  pallor,  good  nutrition,  a  spotted  black 
line  on  the  gums  at  the  border  of  the  incisors  and  bicuspids.  No 
blue  patches  an3rwhere.  In  the  left  back  there  is  an  area  of  diminished 
sensation,  as  shown  in  Fig.  204.  Otherwise  the  chest  shows  nothing 
abnormal.  The  radials  are  somewhat  tortuous  and  thickened.  All 
the  reflexes  are  normal  and  there  is  no  muscular  weakness.  The  ears 
are  negative,  likewise  the  eye-grounds.  Blood  examination  shows 
red  cells,  5,000,000;  whites,  9400;  hemoglobin,  60  per  cent.  The 
urine  is  normal. 

Discussion. — This  patient  is  burdened  by  exposure  to  lead-poison- 


544  DIFFERENTIAL  DIAGNOSIS 

ing  and  to  alcohol.  In  view  of  his  occupation  we  may  imagine  that  the 
brain  fever  of  eighteen  years  ago  was  very  possibly  a  lead-encephal- 
opathy. 

Whether  the  traumatism  of  ten  years  ago  has  any  special  rela- 
tion to  his  present  symptoms  I  cannot  say,  but  it  seems  to  me  very 
doubtful. 

At  the  present  time  he  is  troubled  not  only  by  fainting,  but  by 
vertigo,  vomiting,  nosebleed,  and  abdominal  pain.  The  last  two  of 
these  symptoms  are  not  ordinarily  associated  with  fainting  and  sug- 
gest that  some  other  malady  is  at  work.  Another  bizarre  symptom 
is  his  difficulty  in  holding  up  his  head,  which  in  a  man  of  forty- two  is 
more  notable  than  during  the  first  year  of  Ufe. 

The  other  points  of  note  in  this  case  are  the  patch  of  diminished 
sensation  in  the  left  back,  the  evidences  of  arteriosclerosis,  and  the 
anemia. 

Out  of  this  rather  miscellaneous  group  of  complaints  and  lesions, 
several  draw  attention  strongly  toward  lead-poisoning  as  a  possible 
diagnosis.  This  would  explain  the  stomachache,  the  arterial  changes, 
the  anemia,  the  nosebleed,  and  very  possibly  the  nervous  lesions 
responsible  for  his  patch  of  anesthesia  and  his  difficulty  in  holding  up 
his  head.  The  condition  of  the  gums  strongly  supports  this  hypoth- 
esis, but  before  committing  ourselves  absolutely,  however,  certain 
alternatives  should  be  mentioned. 

Brain  tumor  could  cause  many  of  his  symptoms,  but  the  negative 
eye-grounds,  the  absence  of  focal  symptoms,  and  of  any  persistent 
headache  are  against  any  such  idea.  Arteriosclerosis  might  cause  all 
his  symptoms,  except  his  anemia  and  the  black  spots  upon  his  gums. 
Doubtless  he  has  some  arteriosclerosis,  but  in  all  probability  plumbism 
is  its  cause. 

Alcoholism  would  account  for  his  vertigo,  possibly  his  fainting, 
certainly  his  vomiting,  but  beyond  that  it  cannot  help  us  to  straighten 
out  the  complicated  symptomatology  of  the  case. 

Outcome. — The  patient  was  given  magnesium  sulphate,  ^  ounce 
before  breakfast  daily,  and  potassium  iodid,  5  gr.,  twice  a  day.  He 
improved  steadily  and  had  no  more  fainting  attacks,  but  during  the 
nights  of  the  9th  and  loth  had  abdominal  pain,  keeping  him  awake 
about  two  hours,  and  relieved  by  pressure  and  hot-water  bag.  On 
the  12th  of  December  he  was  so  much  better  that  he  was  allowed  to 
go  home.  For  the  past  seven  years  he  has  worked  making  white  lead 
and  his  hands  are  constantly  covered  with  it.  He  always  washes  them 
before  eating,  but  some  of  the  paint  sticks  about  the  finger-nails. 


PAINTING  545 


Case  238 


An  Irish  butler  of  thirty-one  entered  the  hospital  May  i6,  1907, 
complaining  of  aching  in  the  region  of  the  ensiform,  relieved  by  food 
for  several  hours,  also  by  hot  drinks.  Two  weeks  before  this  he  began 
vomiting  early  in  the  morning,  the  vomitus  being  sour  and  relieving 
the  pain.  Lavage  also  relieved  him.  His  appetite  was  good,  bowels 
constipated.  The  previous  year  he  had  been  operated  upon;  the  gall- 
bladder was  drained  and  some  adhesions  about  it  separated.  The 
appendix  was  also  removed  at  this  time,  though  no  disease  was  found 
in  any  of  these  viscera.  Another  operation  was  done  February,  1907, 
and  some  more  adhesions  freed.  After  this  he  was  well  for  two  months. 
At  the  time  of  his  first  entrance  to  the  Massachusetts  Hospital  he  was 
very  neurotic  and  had  but  little  pain.  Examination  of  his  stomach, 
both  fasting  arid  after  test-meal,  showed  normal  contents  and  physical 
examination  was  otherwise  negative,  except  that  his  stomach  after 
inflation  reached  2  inches  below  the  navel.  Operation  was  consid- 
ered, but  not  advised. 

January  29,  1908,  he  returned,  stating  that  four  days  ago,  while 
working  as  a  waiter,  he  fainted  away  three  times.  During  that  night 
and  the  following  day  he  passed  four  black  stools.  Since  then  he  has 
had  some  epigastric  pain,  which  last  night  kept  him  awake,  and  he  has 
grown  very  pale  and  weak. 

Physical  examination  was  again  negative,  except  that  his  hemo- 
globin was  reduced  to  75  per  cent.,  and  his  stools  were  strongly  posi- 
tive to  guaiac  during  the  first  few  days.  After  that  time  they  were 
negative.  There  was  no  fever.  He  had  occasional  night  attacks  of 
pain  in  the  upper  abdomen,  but  under  a  diet  of  milk  and  Hme-water 
continued  for  two  weeks,  and  then  followed  by  carbohydrate  and 
milk  diet,  he  did  very  well,  and  left  the  hospital  March  26th.  Such 
pain  as  he  had  at  the  end  of  this  time  came  about  three  hours  after 
eating,  and  was  relieved  by  soda.  He  was  again  in  the  hospital  No- 
vember 3  to  December  9,  1908,  having  had  pain  off  and  on  since  his 
previous  entrance.  Meat-free  diet  and  sodium  bicarbonate  reheved 
him  as  before. 

Discussion. — Fainting  associated  with  black  stools  leaves  Uttle 
doubt  of  its  cause.  In  the  majority  of  cases  such  an  association  is 
not  noticed  by  the  patient,  but  when  he  is  aware  of  it  and  remembers 
to  tell  his  doctor,  the  latter  can  hardly  be  excused  for  not  putting 
two  and  two  together  and  recognizing  that  the  fainting  is  due  to 
hemorrhage.     Among  the  causes  of  gross  bleeding  from  the  bowel  in 

Vol.  11—35 


546  DIFFERENTIAL   DIAGNOSIS 

a  man  of  this  age,  typhoid  fever,  cirrhosis  of  the  liver,  peptic  ulcer 
are  the  only  ones  of  any  importance.  Typhoid  can  easily  be  ruled  out 
by  the  absence  of  fever  and  other  evidences  of  infection.  Cirrhosis 
is  possible,  but  there  is  nothing  to  suggest  it.  On  the  other  hand, 
the  symptoms  ai*e  all  such  as  one  expects  with  peptic  ulcer,  a  diag- 
nosis which  doubtless  would  have  been  made  long  ago  had  we  not 
been  thrown  off  the  track  by  the  previous  operation,  at  which  the  real 
cause  of  the  trouble  was  not  recognized,  though  it  must  have,  in  all 
probabiUty,  been  present  at  that  time. 

Faintness  from  this  cause  is  not  unusual  and  is  sometimes  very 
sudden.  I  have  known  two  patients  to  fall  out  of  their  chairs  in  such 
a  fainting  attack. 

Outcome. — Soon  after  this  Dr.  E.  A.  Codman  operated  on  him 
and  found  a  duodenal  ulcer  with  marked  local  peritonitis.  Posterior 
gastro-enterostomy  was  done. 

April  24,  1913,  he  was  reported  to  be  perfectly  well  and  working 
regularly. 

Case  239 

A  janitor  of  thirty-seven  entered  the  hospital  January  19,  1909, 
for  the  second  time,  largely  on  account  of  fainting  spells  which  have 
troubled  him,  off  and  on,  for  the  past  ten  months.  At  the  time  of  his 
first  entry,  January  i,  1908,  he  stated  that  he  had  rheumatic  fever  at 
fifteen  and  again  at  twenty-five,  and  was  told  that  he  had  severe 
heart  trouble  with  his  second  attack,  but  completely  recovered  from 
it,  so  far  as  he  knows.     He  denied  venereal  disease. 

About  fifteen  years  ago  he  did  not  feel  well  and  went  to  a  doctor, 
who  found  albumin  in  his  urine.  Under  treatment  this  disappeared, 
and  he  was  perfectly  well  until  five  years  ago,  when  he  again  consulted 
a  doctor,  who  found  albumin  once  more  and  put  him  to  bed  for  a 
month.  The  albumin  then  disappeared  as  before,  and  after  a  couple 
of  months  more  of  convalescence  he  went  back  to  work. 

In  the  spring  of  1907  he  again  felt  weak;  he  gave  up  his  job  as 
janitor  in  June  and  went  to  work  on  a  farm,  where  he  remained  until 
the  end  of  November.  He  worked  hard  all  the  time  and  felt  perfectly 
well.  He  returned  to  Boston  in  December  and  worked  at  various 
jobs.  In  December,  1907,  a  week  before  the  time  of  his  first  entrance 
to  the  hospital,  he  began  to  feel  faint  and  saw  spots  before  his  eyes, 
but  did  not  actually  faint  away.  Four  days  later  his  face  and  his 
feet  swelled,  but  he  had  no  other  symptoms  at  the  time  of  entering 
the  hospital  on  New  Year's  Day,  1908.     At  that  time  physical  ex- 


FAINTING 


547 


animation  was  negative,  save  for  puffiness  of  the  face  and  the  follow- 
ing cardiac  abnormalities:  The  heart's  sounds  were  best  heard  and  the 
left  border  of  dulness  found  at  a  point  f  inch  outside  the  left  nipple; 
the  right  border  dulness  i  j  inch  to  the  right  of  midsternum.  A  moder- 
ate systolic  murmur  was  heard  at  the  apex,  transmitted  to  the  axilla 
and  all  over  the  precordia.  The  pulmonic  second  sound  was  con- 
siderably louder  than  the  aortic.  Systolic  blood-pressure  was  175. 
Urine  averaged  40  ounces  in  twenty-four  hours,  with  a  specific  gravity 
of  102 1  and  a  very  large  amount  of  albumin.  Many  hyaline  and  fine 
granular  casts,  some  with  red  corpuscles  and  fat  drops  adherent. 
A  few  highly  refractile  casts.  Occasionally  an  epithelial  cast.  Blood 
normal;  fundus  oculi  also  normal. 

January  5th  slight  edema  appeared  in  the  legs  and  in  the  ab- 
dominal wall.  There  were  occasional  attacks  of  shortness  of  breath 
in  the  night. '  On  the  19th  ascites  was  made  out,  but  by  the  22d  this 
had  almost  disappeared,  and  on  the  29th  he  was  allowed  to  go  home. 

Discussion. — This  is  the  type  of  case  to  which  Libman,  of  New 
York,  has  drawn  attention  in  a  recent  series  of  interesting  papers, 
the  last  of  which  was  published  in  the  Transactions  of  the  Associa- 
tion of  American  Physicians,  vol.  xxviii,  p.  307.  Libman  called  at- 
tention specially  to  the  fact  that  attacks  of  rheumatic — that  is,  strep- 
tococcic— endocarditis  such  as  affected  this  patient  in  his  early  life 
are  likely  at  the  same  time  to  produce  renal  lesions  which  appear  much 
later  in  life,  after  a  period  of  intervening  good  health,  in  the  form  of 
chronic  nephritis.  Whether  the  renal  lesions  are  actually  embolic 
in  type,  as  Libman  supposes,  or  whether  they  are  produced  by  cir- 
culating toxins,  need  not  at  present  be  decided. 

For  the  past  fifteen  years  the  patient  has  certainly  had  evidence 
of  glomerulonephritis.  At  the  present  time  the  condition  of  the 
urine  and  blood-pressure  leaves  little  room  for  doubt  that  his  present 
cerebral  symptoms  are  due  to  his  kidney  trouble  and  to  the  vascular 
cerebral  crises  associated  with  it. 

Outcome. — He  returned  a  year  later,  January  19,  1909,  on  account 
of  the  fainting  spells  above  referred  to.  He  has  no  headache,  no 
dropsy,  and  no  vomiting.  Nocturia,  four.  He  comes  this  time 
wholly  for  the  fainting  spells  and  for  weakness. 

Physical  examination  was  essentially  as  before,  but  edema  w^as 
absent.  Systolic  blood-pressure,  170;  urine,  0.3  per  cent,  albumin; 
casts  much  fewer  than  before.     He  went  home  on  the  23d. 


548  DIFFERENTIAL  DIAGNOSIS 

Case  240 

A  Scotch  housewife  of  fifty-seven  entered  the  hospital  January  9, 
191 1.  Her  family  history  was  good.  For  about  eleven  years  she  has 
been  troubled  by  "biliousness,"  coming  about  once  a  week  and  cul- 
minating in  the  vomiting  of  bitter  green  fluid,  reheved  by  soda  water 
and  not  accompanied  by  pain.  Menopause  occurred  seven  years  ago. 
In  August,  1 9 10,  she  had  swelling  and  pain  in  her  knees,  but  was  not 
in  bed  with  it.  Four  weeks  later,  after  the  swelling  had  disappeared, 
there  was  much  itching  in  both  legs  for  a  month,  thought  by  her 
physician  to  be  connected  with  varicose  veins.  This  itching  has 
occurred  at  times  since. 

For  eight  weeks  she  has  had  many  chills  and  two  periods  of  un- 
consciousness, the  first  eight  weeks  ago  and  the  second  six  weeks  ago, 
each  accompanied  by  a  chill,  with  cyanosis  and  unconsciousness  last- 
ing a  few  minutes  only,  though  the  chill  lasted  four  hours.  In  the 
second  attack  she  fell. 

For  four  weeks  she  has  vomited  each  night,  following  an  attack 
of  coUc  at  about  2  a.  m.  The  attacks  are  in  the  left  side  of  the  ab- 
domen, later  in  the  back.  The  pain  is  sharp,  but  does  not  radiate. 
During  this  time  she  has  eaten  but  little,  and  feels  very  much  as  she 
usually  did  in  the  early  months  of  her  pregnancies.  Her  bowels  are 
costive.  There  is  no  nocturia.  The  urine  was.  examined  a  week  ago 
and  found  normal.  Two  years  ago  she  weighed  160  pounds,  with 
clothes;  now,  137  pounds,  without  clothes.  She  thinks  she  has  lost  a 
good  deal  of  weight  in  the  last  few  months. 

Physical  examination  showed  a  patient  well  nourished.  Normal 
pupils  and  reflexes.  Chest  and  abdomen  negative,  except  for  slight 
tenderness  on  pressure  on  the  left  flank.  On  the  front  of  the  right 
thigh  there  was  a  white  scar  the  size  of  a  dime.  Systolic  blood- 
pressure,  170.  Urine  averaged  30  ounces  in  twenty-four  hours;  specific 
gravity,  1007  to  loio.  Slight  trace  of  albumin.  There  was  a  small 
amount  of  pus  and  red  corpuscles  in  a  catheter  specimen.  No  casts. 
White  cells,  12,000,  with  a  slight  polynuclear  leukocytosis;  hemo- 
globin, 85  per  cent.  Wassermann  reaction  negative.  Fundi  negative. 
The  urine  showed  a  pure  culture  of  colon  bacilli,  but  20  minims 
injected  into  a  guinea-pig  produced  no  results.  X-ray  showed  appa- 
rently two  stones  in  the  left  kidney.  The  patient  continued  to  vomit 
despite  diet  and  purgation  and  took  very  Httle  nourishment. 

January  i6th,  soon  after  breakfast,  she  began  to  have  peculiar 
spasmodic  attacks,  as  follows:    She  lies  quiet,  the  radial  pulse  disap- 


FAINTING  549 

pears,  and  the  heart's  sounds  are  reduced  to  a  very  slight  ticking 
sound  corresponding  to  first  sound,  and  best  heard  just  to  the  left 
of  the  sternum.  The  rate  is  70  to  80  and  the  rhythm  quite  regular. 
No  second  sound  is  heard.  In  five  or  ten  seconds  the  face  becomes 
pale,  then  gray,  the  eyelids  droop,  and  eyeballs  roll  up  with  widely 
dilated  and  non-reacting  pupils.  Then  follow  a  few  quick,  deep  respira- 
tions. Then  twitching  of  both  arms,  with  or  without  a  strong  back- 
ward extension  of  the  neck.  All  of  this  lasts  perhaps  twenty  to  thirty 
seconds.  Then  there  come  a  few  violent  irregular  thumpings  of  the 
heart,  the  eyes  and  mouth  become  greatly  puckered,  then  the  face 
relaxes  and  becomes  pink,  the  spasmodic  movements  of  the  arms 
cease,  the  pupils  quickly  contract  to  their  normal  size,  and  the  patient 
looks  up  in  mute  astonishment  as  if  waking  from  a  bad  dream.  Within 
a  moment  another  seizure  may  occur. 

In  the  interims  the  pulse  is  regular,  at  about  40  per  minute,  and 
there  seem  to  be  two  beats  in  the  neck  veins  for  every  beat  at  the 
wrist.  During  the  day  of  January  i6th  she  had  twenty-five  attacks 
of  this  kind  and  ten  to  twenty  in  the  following  night.  In  one  of  these 
attacks,  while  the  nurse  had  gone  for  a  glass  of  water,  she  wriggled 
out  of  bed. 

Discussion. — Bilious  attacks  are  among  the  most  mysterious 
and  tantalizing  of  all  the  symptoms  of  which  our  patients  tell  us. 
They  always  seem  to  know  so  much  about  them  and  we  so  httle. 
In  the  present  case  there  is  reason  to  suspect  that  these  attacks  have 
the  same  fundamental  cause  as  the  later  periods  of  unconsciousness 
and  chills. 

The  condition  during  the  last  four  weeks  seems  to  be  somewhat 
different.  The  nightly  attacks  of  abdominal  pain  and  the  marked  loss 
of  weight  seem  to  point  to  something  different  from  what  is  suggested 
in  the  earlier  history.    Presumably,  she  has  two  separate  diseases. 

The  nocturnal  attacks,  when  taken  in  connection  with  the  physical 
signs  in  the  left  flank,  the  condition  of  the  urine,  and  the  x-ray  picture, 
point  pretty  clearly  to  renal  stone. 

Quite  separate  from  these  are  the  attacks  of  January  i6th  and 
the  following  night.  These  evidently  involve  the  brain,  and  our 
further  consideration  must  be  directed  to  an  attempt  to  make  out 
what  brain  trouble  she  has.  First  of  all,  we  may  note  that  there  are 
no  infectious  symptoms,  no  persistent  headache,  and  no  optic  neuritis; 
brain  tumor  is,  therefore,  improbable.  Can  we  account  for  the  at- 
tacks as  uremia?  Possibly,  although  one  would  expect  a  higher  blood- 
pressure  and  more  marked  urinary  abnormalities. 


550  DIFFERENTIAL  DIAGNOSIS 

Vascular  crises,  associated  with  arteriosclerosis,  give  perhaps  the 
most  tempting  explanation.  The  pulse  is  slow  enough  for  a  Stokes- 
Adams  syndrome,  and  to  some  of  those  who  saw  the  case  this 
seemed  obviously  the  diagnosis.  No  satisfactory  tracings,  however, 
were  obtained  from  the  neck  veins,  and  I  have  long  ago  come  to  dis- 
trust any  diagnosis  of  heart-block  based  on  simple  observation  of 
neck  pulsation.  On  the  whole,  then,  the  diagnosis  seemed  to  rest 
between  Stokes-Adams'  disease  and  vascular  crises.  The  cause  of 
death  is  not  obvious,  but  is  presumably  the  same  as  that  which  pro- 
duced the  cerebral  attacks.  The  loss  of  weight  must  be  attributed 
to  arteriosclerosis. 

Outcome. — On  the  day  following  she  died  in  an  attack  which  began 
just  like  the  rest.  Autopsy  showed  arteriosclerotic  nephritis  with  a 
stone  in  the  pelvis  of  the  left  kidney  and  slight  hydronephrosis,  also 
some  calcium  oxalate  stones  in  the  tissue  of  both  kidneys;  slight 
hypertrophy  and  dilatation  of  the  heart;  chronic  pleuritis,  obsolete 
tuberculosis  at  the  apices  of  both  lungs,  and  cholelithiasis.  The  heart 
showed  no  lesion  in  the  region  of  His'  bundle  and  was  not  remark- 
able save  as  above  noted.    The  brain  was  normal. 

Case  241 

A  contractor  of  sixty-five  entered  the  hospital  November  30,  1910. 
His  family  history  was  excellent.  He  has  been  unable  for  some  time 
to  sleep  on  his  left  side.  He  cannot  say  why.  He  has  been  active 
and  strong  muscularly,  but  has  had  some  sort  of  stomach  trouble,  the 
nature  of  which  cannot  be  definitely  described.  For  three  months  he 
has  been  losing  weight. 

Ten  years  ago  he  had  an  attack  similar  to  the  present  one,  and 
since  that  time  he  has  had  six  or  seven  in  all.  In  each  of  these  attacks 
he  suddenly  faints,  without  the  least  warning;  once  in  the  middle  of 
a  sentence.  After  ten  or  fifteen  minutes  he  begins  to  recover  and  in 
two  or  three  hours  is  all  right.  During  the  attack  he  is  chilly,  but 
sweats  profusely.  There  has  been  no  convulsion,  no  foam  at  the 
mouth,  no  cry,  and  no  loss  of  sphincteric  control.  A  drink  of  whisky 
appears  to  shorten  the  attacks.  Pallor  and  cyanosis  accompany  them. 
His  last  attack  was  three  months  ago  and  was  longer  than  the  others. 

About  2.15  p.  M.  this  afternoon  he  was  picked  up  on  the  street 
unconscious.  At  5.15  p.  m.  he  recognized  his  son,  but  seemed  still 
much  dazed.  Later  in  the  day  the  patient  showed  sHght  aphasia,  but 
answered  questions  fairly  well,  and  stated  that  at  the  beginning  of  the 
attack  he  noticed  that  he  could  not  use  his  hands  and  that  they  shook 


FAINTING  551 

a  little.  A  window  was  opened,  but  he  does  not  remember  what  hap- 
pened next.  He  has  never  had  dyspnea  or  precordial  pain.  He  was 
examined  after  an  attack  in  1904  and  told  that  his  heart  was  all 
right  and  that  his  fainting  was  caused  by  indigestion  and  worry. 

Physical  examination  showed  well-developed  pupillary  reactions, 
somewhat  sluggish  on  the  left.  Tongue  came  out  straight.  Heart's 
apex  just  outside  the  nipple  line.  Action  slow,  regular,  no  murmurs. 
Pulses  showed  increased  tension.  Systolic  blood-pressure  fell  from 
180  mm.  Hg.  at  entrance  to  105  a  week  later.  Pulse-rate  was  in  the 
neighborhood  of  60  throughout  his  week's  stay  in  the  hospital.  Lungs 
and  abdomen  negative.  Reflexes,  motion,  and  sensation  negative. 
Blood  and  urine  normal,  except  for  an  occasional  hyaline  and  granular 
cast  in  the  specimen  of  December  ist. 

On  the  2d  of  December  it  is  noticed  that  the  wrist  reflex  and  the 
Achilles  reflex  are  slightly  increased  on  the  right  and  the  cremasteric 
diminished  on  the  right.  Thinking  and  talking  are  slow  and  un- 
satisfactory. He  can  scarcely  read  or  spell,  though  he  used  to  be  pro- 
ficient in  these  respects. 

Discussion. — Fainting  attacks  beginning  at  the  age  of  fifty-five 
are,  of  course,  spurious.  No  one  has  true  fainting  attacks  independent 
of  organic  disease  at  that  age,  and  most  attacks  which  receive  that 
name,  in  people  past  middle  life,  turn  out  to  be  due  to  uremia  or  arte- 
riosclerosis. Yet,  when  the  mistaken  diagnosis  of  fainting  is  avoided, 
the  other  commonest  mistake  is  to  refer  such  attacks  to  indigestion. 
This  blunder  also  was  committed  in  the  present  case.  It  is  high  time 
that  we  all  came  to  realize  that  indigestion  never  causes  marked  cere- 
bral symptoms,  and  that  the  indispositions  of  prominent  elderly  men 
at  banquets  and  elsewhere,  though  ordinarily  called  indigestion,  are 
usually  of  vascular  origin  and  mean  disease  of  the  heart,  brain,  or 
kidney. 

In  the  present  case  the  aphasia,  the  paretic  hands,  the  suggestion 
of  hemiplegia  contained  in  the  physical  examination,  the  high  blood- 
pressure  and  mental  changes,  make  a  diagnosis  of  cerebral  arterio- 
sclerosis inevitable.  Whether  an  actual  hemorrhage  has  taken  place, 
or  whether,  as  is  more  probable,  we  are  dealing  with  a  vascular  crisis, 
cannot  be  positively  decided.  Such  attacks  are  sure  to  be  repeated 
and  become  more  severe. 

Outcome. — By  December  9th  he  could  read  and  spell  normally, 
walked  strongly,  and  was  allowed  to  go  home. 


552 


DIFFERENTIAL  DIAGNOSIS 


Case  242 

A  pedler  of  sixty-five  entered  the  hospital  March  22,  191 1.  His 
family  history  was  negative.  He  has  always  been  well  until  six  weeks 
ago,  February  15,  191 1,  when  he  suddenly  fainted  in  a  store  and  fell, 
cutting  his  head.  Within  a  minute  he  was  conscious  and  clear-headed, 
but  had  a  peculiar  throbbing  in  the  epigastrium  and  felt  weak  for  a 
few  minutes.  He  was  taken  to  the  hospital  room  within  the  store 
and  his  wound  sewed  up,  but  fainted  again  and  was  unconscious  for 

thirty  seconds.  He  was  then  sent 
to  the  IVIunicipal  Relief  Station, 
where  he  fainted  once  more  and 
stayed  in  bed  twenty-four  hours, 
after  which  he  was  sent  home  in 
an  ambulance  and  has  remained  in 
bed  since.  During  the  past  six 
weeks  he  has  had  many  attacks 
almost  exactly  like  the  first,  but 
for  the  last  three  days  these  at- 
tacks have  ceased.  There  have 
never  been  any  convulsive  move- 
ments in  the  attacks,  no  dyspnea, 
cough,  or  cyanosis,  no  headache 
or  vertigo,  no  urinary  symptoms. 
He  says  he  has  eaten  almost 
nothing.  His  time  has  appar- 
ently been  consumed  in  taking 
many  medicines,  powders  and 
pills,  both  day  and  night.  He 
says  he  has  bushels  of  empty 
bottles  as  a  result. 


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blood-pressure  (starred  lines)  in  Case  242. 
Note  also  the  slow  pulse,  subnormal  tem- 
perature, and  low  urinary  output  (cross- 
dotted  line)  recorded  in  ounces. 


Physical  examination  shows  nothing  remarkable  except  as  con- 
cerns the  circulatory  system.  The  heart's  dulness  extends  to  the 
second  rib  above  and  11  cm.  to  the  left  of  the  median  line,  2  cm. 
inside  the  nipple.  Right  border  behind  the  sternum  at  a  point  not 
clearly  determined.  The  impulse  is  not  seen  or  felt.  The  sounds  are 
regular  and  forceful.  A  rough  systolic  murmur  is  heard  all  over  the 
precordia,  loudest  just  inside  the  apex.  The  neck  veins  are  distended 
and  pulsate  twice  between  each  of  the  radial  beats,  which  occur,  as 
a  rule,  from  30  to  35  times  a  minute.  The  urine  is  negative.  The 
blood-pressure,  systolic  and  diastolic,  is  recorded  in  Fig.  205.    Fluoro- 


FAINTING  553 

scopic  examination  is  negative.  Atropin  and  strychnin  subcuta- 
neously  have  no  special  effect.  Blood  and  urine  show  nothing  of 
importance. 

Discussion. — Of  course,  it  was  not  a  fainting  fit  which  happened 
to  this  patient  six  weeks  ago.  There  are  many  such  tales  about 
people  of  his  age,  tales  of  falling  down  stairs  and  striking  the  head, 
tales  of  stumbling  and  falling  with  a  stunning  blow.  Many  of  such 
stories  go  hindside  foremost.  What  has  happened  is  that  the  person 
has  become  unconscious  and  therefore  falls;  not  fallen  and  therefore 
becomes  unconscious. 

In  the  present  case  it  might  perfectly  well  have  been  a  fainting  fit 
had  it  occurred  in  a  younger  person,  but  at  sixty-five  we  should  be 
very  skeptical  of  any  diagnosis  of  fainting. 

When  we  come  to  the  positive  side  of  the  question,  we  must  con- 
fess that  without  polygraphic  tracing  from  the  neck  and  wrist  we 
cannot  be  certain  whether  the  observation  of  two  venous  beats  be- 
tween each  pair  of  radial  beats  is  true  or  not.  The  attack  seems  like 
one  of  Stokes-Adams'  disease,  but  there  are  many  mistakes  in  this 
diagnosis  unless  the  most  accurate  methods  of  observation  are  used. 
If  the  attack  was  not  Stokes-Adams'  disease  it  was,  in  all  probability, 
a  vascular  crisis. 

Outcome. — He  left  the  hospital  April  12th,  having  had  no  attack 
of  syncope  in  the  meantime. 

Case  243 

A  chauffeur  of  thirty-six  entered  the  hospital  July  10,  191 1.  His 
family  history  and  past  history  are  excellent.  Ten  years  ago  the 
patient  was  very  active  and  worked  in  a  gymnasium.  Since  he  gave 
up  exercise,  nine  years  ago,  on  account  of  business,  he  has  been  less 
athletic  than  before,  but  felt  no  other  special  change  until  a  year  ago, 
when  he  began  to  notice  that  he  tired  very  easily  and  had  to  give  up 
his  work  as  chauffeur  for  a. day  or  two  at  a  time.  Nevertheless,  he 
worked,  with  slight  intermissions,  until  two  weeks  ago.  Ten  days 
ago  he  fainted  for  the  first  time  in  his  Hfe,  though  he  has  felt  faint 
several  times  in  the  last  few  months.  Palpitation  and  dyspnea  on 
exertion  have  been  noticed  for  several  months.  The  appetite  has 
been  excellent  until  ten  days  ago;  since  then,  poor.  His  bowels  are 
irregular,  but  usually  constipated.  For  a  week  he  has  noticed  that  his 
mouth  is  sore.  Nine  years  ago  he  weighed  170  pounds;  now,  143 
pounds. 

Physical  examination  shows  evidence  of   some  loss   of  weight. 


554 


DIFFERENTIAL  DIAGNOSIS 


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Fig.  2o6. — Blood  chart  in  Case  243. 


FAINTING 


555 


His  sclerae  slightly  yellow;  mucous  membranes  very  pale.  Pupils 
normal;  knee-jerks  reduced,  but  present.  The  heart  area  is  normal, 
but  the  apex  impulse  is  not  seen  or  felt.  A  blowing  systoHc  murmur 
over  the  whole  precordia,  loudest  at  the  apex.  Lungs  and  abdomen 
negative.     Urine  negative.     Blood  as  in  Fig.  206. 

Discussion. — This  appears  to  be  a  fainting  fit  due  to  general  weak- 
ness, what  might  be  called  the  cachectic  type  of  fainting.  From  the 
history  I  do  not  see  that  any  guess  could  be  made  as  to  the  underlying 
cause  of  his  weakness.  The  blood-picture  leaves  no  doubt  that  the 
diagnosis  is  pernicious  anemia.     Fainting  is  relatively  uncommon 


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Fig.  207. — ^Temperature,  weight,  pulse,  urine,  and  respiration  in  Case  243. 

in  that  disease,  surprisingly  uncommon  when  we  consider  how  great 
must  be  the  degree  of  cerebral  anemia. 

Outcome.— The  patient  gained  4  pounds  in  his  first  week,  but  lost 
2  pounds  in  his  second.  He  ran  a  slight,  irregular  fever,  as  is  shown 
in  Fig,  207.     He  left  on  the  24th,  feeling  better  than  at  entrance. 


Case  244 

An  unoccupied  woman,  aged  twenty-one,  entered  the  hospital 
November  8,  1911.  The  patient's  family  history  and  past  history 
are  excellent.  She  has  never  been  nervous.  Six  months  ago,  without 
known  cause,  she  began  to  have  faintmg  spells,  coming  at  irregular 


556  DIFFERENTIAL   DIAGNOSIS 

intervals,  sometimes  every  day  or  several  times  daily,  sometimes 
only  once  in  a  fortnight.  In  these  attacks  she  loses  consciousness  and 
falls,  sometimes  to  the  floor,  sometimes  to  a  bed,  but  has  never  hurt 
herself.  In  the  attacks  her  arms  and  legs  become  rigid  and  flexed, 
and  when  she  is  coming  out  of  them  her  mouth  "works."  The  attacks 
last  fifteen  to  thirty  minutes,  and  are  followed  by  a  period  of  weak- 
ness lasting  about  half  an  hour.  They  are  more  troublesome  just 
before  the  menstrual  period.  In  the  interval  she  feels  entirely  well. 
She  is  occasionally  nauseated  after  one  of  these  fits,  but  never 
vomits.  Her  eyesight  is  good  and  she  has  no  other  symptoms  of 
any  kind. 

Physical  examination  shows  good  nutrition;  small  white  scars 
on  the  cornea  of  each  eye;  the  right  pupil  larger  than  the  left,  both 
reacting  normally.  A  soft-blowing  systolic  murmur  is  heard  at  the 
apex,  not  widely  transmitted.  Pulmonic  second  sound  is  greater 
than  the  aortic  second,  but  not  accentuated.  The  right  pulse  larger 
than  the  left.  The  lungs  show  nothing  abnormal.  There  is  a  slight 
general  tenderness  in  the  lower  abdomen,  but  nothing  else  of  note. 
The  hymen  is  normal,  the  labia  not  hypertrophied  or  pigmented. 
Reflexes  normal.  The  left  leg  slightly  smaller  than  the  right.  Systolic 
blood-pressure,  115.  Wassermann  reaction  is  recorded  as  suspicious, 
but  not  positive.  Temperature,  pulse,  respiration,  blood,  and  urine 
normal. 

Discussion. — Are  we  dealing  with  organic  or  with  functional  dis- 
ease? In  favor  of  some  organic  lesion  is  the  smallness  of  the  left 
pulse,  the  left  pupil,  and  the  left  leg,  the  suspicious  Wassermann 
reaction,  the  scars  upon  the  cornea.  None  of  these  data,  however,  is 
conclusive. 

In  favor  of  functional  disease  is  the  age  and  sex,  the  connection 
of  the  symptoms  with  the  menstrual  period,  the  negative  physical 
examination,  and,  above  all,  the  fact  that  the  attacks  are  never 
nocturnal,  never  injurious  to  the  patient,  and  never  present  any  of 
the  characteristic  signs  of  epilepsy. 

The  attacks  are  obviously  too  long  to  deserve  the  term  "fainting 
fit,"  and  the  rigidity  during  them  is  quite  uncharacteristic.  On  the 
other  hand,  both  of  these  features  are  what  we  expect  in  hysteria^ 
and  I  see  no  good  reason  to  doubt  this  diagnosis. 

Outcome. — During  her  five  days  in  the  hospital  the  patient  had  no 
attack  and  refused  treatment. 


FAINTING  557 


Case  245 


A  factory  girl  of  eighteen  entered  the  hospital  March  14,  191 2. 
Her  family  history  and  past  history  not  remarkable,  though  the 
patient  eats  15  cents'  worth  of  candy  every  other  day.  Ten  months 
ago,  without  known  cause,  the  patient  began  to  have  fainting  spells. 
In  the  first  three  weeks  they  came  fifteen  to  twenty  times  a  day. 
Since  then  they  have  grown  more  infrequent,  until  now  they  only 
come  once  a  month.  They  are  often  preceded  by  lack  of  appetite, 
headache,  and  drowsiness.    After  the  fainting  fit  she  feels  better. 

In  the  attack  she  sometimes  falls,  bumping  her  head.  Sometimes 
she  is  able  to  get  a  glass  of  water  and  recover  without  losing  con- 
sciousness. She  has  no  twitching  or  convulsions  and  no  warning  of 
the  approach  of  an  attack,  except  through  the  general  symptoms  above 
mentioned.  The  attacks  may  occur  at  any  time  of  day,  but  never 
during  the  night.  Except  during  the  first  three  months  of  her  trouble 
she  has  worked  steadily. 

She  has  no  appetite  at  the  present  time  and  her  food  tastes  queer 
to  her.  Her  bowels  are  regular.  She  eats  at  a  restaurant,  where  her 
food  costs  $3  a  week.     She  sleeps  well. 

On  physical  examination  the  patient  is  pale  and  looks  tired. 
Pupils  and  tendon  reflexes  normal.  Viscera  negative.  Blood  and 
urine  negative.  No  fever  in  ten  days'  observation.  Systolic  blood- 
pressure,  120  mm.  Hg. 

Further  investigation  showed  that  she  lived  in  a  room  with  her 
sister  and  in  the  same  house  with  a  girl  chum,  whose  brother  is  said 
to  be  engaged  to  the  patient's  sister.  The  chum's  brother  and  father 
drink  much  and  work  little,  and  it  is  thought  by  some  friends  that  the 
three  girls  support  the  two  men.    All  three  girls  work  in  an  ink  factory. 

A  friend  describes  an  attack  which  took  place  at  a  lecture.  The 
patient's  neck  gradually  stiffened,  head  drawn  back,  eyes  closed. 
She  then  slipped  unconscious  between  the  seats  and  remained  so  for 
five  or  six  minutes.  The  legs  were  stiff  and  straight.  There  was  no 
cry  and  no  convulsion,  except  that  while  slowly  coming  out  of  the 
attack  there  were  slow  spasms  of  the  arms  and  legs.  On  the  24th 
she  had  an  attack,  beginning  with  a  shuddering  sort  of  tremor,  with 
the  legs  stiff  and  the  eyes  tightly  closed.  She  was  then  referred  to  the 
Social  Service  Department  for  more  thorough  investigation. 

Discussion. — The  poor  hygienic  and  mental  conditions  surround- 
ing the  patient  seem  in  all  probability  of  importance,  whether  as 
aggravating  or  producing  the  attack.     The  most  important  diagnostic 


550  DIFFERENTIAL  DIAGNOSIS 

fact  is  the  negative  physical  examination,  especially  when  considered 
in  connection  with  the  patient's  age  and  sex.  Clearly,  we  are  not 
dealing  with  faintmg  spells,  for  these  never  occur  fifteen  or  twenty 
times  a  day,  nor  does  a  person  feel  relieved  after  a  fainting  fit. 

The  description  of  the  attack,  beginning  with  spasm  and  rigidity, 
is  strongly  suggestive  of  hysteria,  and  in  the  absence  of  physical 
signs  no  other  diagnosis  is  possible. 

Outcome. — Worries  and  mental  conflicts  sufficient  to  produce  her 
S}Tnptoms  were  found.  November  29,  1912,  she  was  better  and  having 
much  fewer  attacks. 


CHAPTER  XIII 

HOARSENESS 

Cases  of  hoarseness  may  be  divided  into  those  which  are  acute 
and  usually  of  trifling  importance,  and  those  which  are  chronic  and 
usually  serious.  Any  one  who  shouts  much  at  a  college  game  or  a 
political  rally  acquires,  I  take  it,  an  acute  laryngitis  as  the  cause  of  his 
inevitable  hoarseness.  Just  how  this  irritation  is  produced  I  do  not 
know.  If  a  person  knows  how  to  use  his  voice,  he  may  make  a  great 
deal  more  noise  than  his  neighbor  who  gets  hoarse,  and  yet  retain 
his  voice  quite  clear.  In  some  way  it  is  the  misuse,  rather  than  the 
simple  overuse,  of  the  voice  that  produces  such  trouble. 

After  an  ordinary  acute  laryngitis,  such  as  occurs  as  part  of  a 
"common  cold,"  men's  voices  behave  quite  differently  from  those 
of  women.  In  men  the  vocal  cords  slacken  down,  the  voice  becomes 
a  deep  bass,  but  is  seldom  lost  altogether.  In  women,  on  the  other 
hand,  we  see  no  such  marked  lowering  in  the  pitch  of  the  voice,  but  it 
is  far  more  common  to  see  complete  aphonia  or  voicelessness  after 
slight  laryngitis.  This  is  of  considerable  importance  in  connection 
with  the  explanation  of  what  is  ordinarily  called  "hysteric  aphonia." 
Such  aphonia  is  usually  preceded  by  an  attack  of  ordinary  acute 
laryngitis.  It  does  not  come  on  from  purely  psychic  causes,  as  a 
rule,  yet  it  is  not  independent  of  psychic  factors.  The  connection 
between  the  cerebral  innervation  (what  we  call  the  will)  and  the  vocal 
cords  is  temporarily  lost  as  the  result  of  the  laryngitis. 

This  is  the  first  step  in  the  process.  Now,  if  there  is  any  con- 
genital tendency  to  a  pathologic  forgetfulness  or  spKtting  up  of  the 
mind  into  mutually  unconscious  parts,  if,  in  other  words,  there  is  any 
tendency  to  hysteria,  there  may  be  considerable  difhculty  in  re- 
estabUshing  the  patient's  memory  of  how  to  talk.  When  this  difh- 
culty  occurs  and  prolongs  the  aphonia  after  the  laryngitis  has  disap- 
peared we  call  it,  very  naturally,  hysteria,  but  we  should  bear  in  mind 
that  such  an  attack  may  occur  in  a  person  who  is  not  hysteric,  in  the 
sense  of  showing  any  other  manifestation  of  that  disease.  In  other 
words,  there  is  probably  enough  tendency  to  hysteria  in  a  great 
many  of  us  to  result  in  a  hysteric  aphonia,  provided  the  connection 

559 


560  DIFFERENTIAL   DIAGNOSIS 

between  the  brain  and  the  vocal  cords  were  once  broken  up  by  the 
lesion  of  laryngitis.  In  men  this  break  does  not  occur  at  all  frequently ; 
in  all  probability  this  is  one  of  the  reasons  for  the  infrequency  of 
hysteric  aphonia  in  men. 

Chronic  hoarseness  or  aphonia  is  due  almost  exclusively  to  organic 
disease  of  the  larynx  or  to  a  pressure  paralysis  produced  by  tumor  or 
aneurysm  of  the  mediastinum.  Occasionally,  the  pressure  of  a  dilated 
heart  in  mitral  stenosis  or  other  cardiac  disease  may  produce  the  same 
effect.  Enlargement  of  the  left  lobe  of  the  thyroid  gland,  occasionally 
enlarged  bronchial  lymph-glands,  may  produce  similar  pressure. 
Tuberculosis  at  the  apex  of  the  lung  may  also  involve  the  recurrent 
(laryngeal)  nerve,  producing  paralysis  of  one  vocal  cord. 

In  the  larynx  itself  tuberculosis,  syphilis,  and  tumors,  benign  or 
malignant,  are  the  commonest  causes  of  hoarseness  or  aphonia. 
The  diagnosis  of  these  conditions  depends,  of  course,  upon  an  expert 
laryngologic  examination. 

Case  246 

A  housewife  of  fifty- two  entered  the  hospital  January  10,  1908. 
Two  of  patient's  sisters  died  of  cancer;  one  sister,  of  "nerves."     Her 


Fig.  208. — Shape  of  nose  in  Case  246. 

husband  died  at  twenty-nine  of  "heart  disease  and  paralytic  shocks." 
She  has  one  child  of  twenty-four,  well.     Many  years  ago  she  had 


Hoarseness  and  Aphonia 


LARYNGITIS  ■{■■■^^^^^■^■■^IHHHI^i^iaB   1836 

PHTHISIS  ^■■■■^^^^^^■■B  670 


NEOPLASM    OF   THE| 
LARYNX  OR  CORDS  J 


112 


ANEURYSM  ^H  65 

HYSTERIC  APHONIA         Hi  59 


HOARSENESS 


561 


diphtheria,  very  severely.  Four  years  ago  she  had  a  partial  hysterec- 
tomy for  uterine  tumors  at  the  Baptist  Hospital,  and  a  year  later  the 
left  kidney  was  removed  "on  account  of  something  which  was  cut  at 
the  previous  operation."  She  passes  water  four  to  ten  times  in  the 
night  and  has  done  so  for  years,  the  amount  varying  with  the  amount 
of  water  she  takes. 

For  three  weeks  she  has  had  a  cold  in  her  head  and  a  sore  throat. 
A  week  ago  she  became  dizzy  and  almost  lost  consciousness  upon  the 
street.  She  staggered,  but  managed  to  get  home.  Since  then  she  has 
had  fever,  sweating,  cough,  sore  throat,  headache,  and  increasing 
hoarseness.  The  cough  has  been  dry  imtil 
to-day,  when  she  began  to  raise  thick,  puru- 
lent sputum.  She  has  been  unable  to 
speak  for  three  days. 

Physical  examination  showed  obesity, 
normal  pupils  and  reflexes,  a  hard,  tender 
gland  at  the  angle  of  the  left  jaw,  herpes 
on  the  nose  and  upper  lip.  The  lungs 
showed  groaning  rales  throughout,  but 
were  otherwise  negative,  likewise  the  heart. 
The  tension  of  the  pulse  seemed  to  be  in- 
creased. The  blood-pressure  was  not  meas- 
ured. Physical  examination  was  other- 
wise negative.  The  shape  of  the  nose  is 
shown  in  Fig.  208.  A  laryngologist  found 
marked  chronic  atrophic  rhinitis,  also 
acute  pharyngitis,  and  laryngitis.  The 
blood  showed  11,000  white  cells,  85  per 
cent,  hemoglobin.    The  urine  was  normal. 

The  temperature  was  as  shown  in  Fig.  209.  During  the  first  few 
nights  of  her  stay  the  patient  had  severe  attacks  of  laryngeal  dyspnea 
with  croupy  cough.  An  intubation  outfit  was  kept  at  hand,  but  was  not 
needed.  By  the  15th  these  attacks  ceased,  but  the  lungs  were  full  of 
dry  and  moist  rales.  The  palatal  reflexes  were  at  this  time  noticed  to 
be  absent,  perhaps  owing  to  her  former  attack  of  diphtheria. 

Discussion. — At  first  sight  of  this  patient  there  is  every  reason 
to  think  that  we  are  deaHng  with  an  acute  laryngitis.  The  three 
weeks'  sore  throat,  cough,  headache,  and  gradually  increasing 
hoarseness  are  fairly  typical  of  that  lesion.  The  herpes  and  gland- 
ular enlargement  in  the  neck  are  wholly  in  keeping  with  such  a 
diagnosis. 

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Fig.  209. — Chart  of  Case  246. 


562  DIFFERENTIAL  DIAGNOSIS 

On  the  other  hand,  the  suggestion  of  syphiHs  in  the  husband,  the 
patient's  habit  of  nocturia,  and  the  absence  of  palatal  reflexes  should 
make  us  pause  for  a  moment  to  consider  whether  some  more  serious  dis- 
ease, or,  in  particular,  whether  syphilis  may  not  be  in  the  background. 

In  a  case  of  this  sort  the  services  of  a  laryngologist  are  essential 
if  diagnosis  is  to  be  prompt  and  sure.  Without  such  help  one  may 
make  a  successful  guess,  but  nothing  more.  In  view  of  the  laryngo- 
scopic  finding  in  the  present  case,  there  seems  no  reason  to  doubt 
that  the  acute  infection  of  the  upper  air-passages  is  all  that  ails  the 
patient. 

Outcome. — On  the  30th  of  January  she  was  sitting  up  and  her 
voice  had  returned.  On  the  5th  of  February  she  seemed  to  be  entirely 
well  and  left  the  hospital.  The  treatment  consisted  of  potassium  iodid, 
10  gr.,  three  times  a  day,  hot  Dobell's  solution  as  a  gargle,  twice 
a  day,  codein,  i  gr.,  every  two  hours  when  needed  for  cough,  inhala- 
tion from  steam,  from  water  containing  i  dram  of  compound  tincture 
of  benzoin  to  the  pint. 

Case  247 

A  nurse  of  twenty-four,  newly  arrived  at  the  Massachusetts 
General  Hospital,  and  previously  employed  for  two  years  in  a  hospital 
for  the  insane,  entered  the  hospital  April  8,  1901.  She  said  she  had 
felt  perfectly  well  until  three  days  ago;  then,  while  on  duty,  she  began 
to  have  headache,  general  muscular  pains,  chilliness,  fever,  sweating, 
nausea,  and  loss  of  appetite.  Her  voice  from  the  first  has  been  more 
and  more  hoarse,  and  yesterday  she  lost  it  altogether.  At  the  be- 
ginning of  her  illness  there  was  a  little  cough,  without  sputum,  and  a 
slight  sore  throat,  with  stiffness  of  the  neck.  She  worked  until 
yesterday,  but  took  to  bed  in  the  evening. 

Physical  examination  showed  good  nutrition,  herpes  of  the  lower 
lip,  reddening  of  the  tonsils  and  pharynx,  tender  glands  in  both  sides 
of  the  neck.  A  soft  systolic  murmur  at  the  apex  of  the  heart,  with- 
out any  other  abnormality.  Lungs,  abdomen,  and  nervous  system 
normal.  Blood  and  urine  normal.  While  in  the  ward  the  patient 
was  apathetic  much  of  the  time,  waking  from  time  to  time  with  a 
start.  She  had  no  cough.  Examination  of  the  larynx,  by  Dr.  Alger- 
non Coolidge,  showed  no  disease. 

Discussion. — Clearly  the  case  began  with  an  acute  infection. 
Everything  in  the  history  and  physical  signs  points  to  this.  An 
aphonia  persisting  after  such  an  infection  is  usually  of  the  type  called 
hysteric,  and  discussed  in  the  introductory  paragraphs  of  this  chapter. 


HOARSENESS 


563 


Outcome. — Dr.  Coolidge's  diagnosis  was  hysteric  aphonia.  By 
the  14th  her  voice  was  normal.  It  appeared  that  she  had  had  a  pre- 
vious hysteric  attack  in  the  winter  before.  On  the  i8th  she  left  the 
ward  well. 

Case  248 

A  jeweler  of  forty-five,  born  in  Turkey,  entered  the  hospital  October 
5,  1906.  The  patient  has  a  negative  family  history  and  has  had  no 
other  illness.     He  denies  venereal  disease. 

Three  years  ago  he  began  to  have  a  shooting  pain  in  the  right 
hand  and  forearm.    Later  a  similar  pain  came  in  the  other  side,  and 


Fig.  210. — Shape  of  head  and  suprasternal  bulge  in  Case  248. 

later  still  the  pain  extended  to  the  shoulders  and  neck,  even  to  the 
head.  This  pain  has  continued  and  has  grown  steadily  worse.  It 
has  been  treated  by  many  doctors  for  rheumatism,  without  rehef ,  and 
has  prevented  work  for  the  past  three  years.  It  has  never  extended 
below  the  level  of  the  shoulders. 

The  patient  had  absolutely  no  other  symptom  until  the  fall  of 
1906,  when  there  appeared  hoarseness  and  a  severe  cough,  often  dry, 
sometimes  with  foamy  sputa,  which  cough  has  continued  up  to  the 
present  time,  except  for  a  slight  remission  during  the  past  summer. 


5^4 


DIFFERENTIAL   DIAGNOSIS 


With  this  cough  there  came  dyspnea  on  exertion.     Five  months  ago 
he  began  to  have  orthopnea  at  night. 

Physical  examination  showed  a  remarkable  flattening  of  the 
back  of  the  head  (Figs.  210,  211).  The  mucous  membranes  were 
cyanotic.  Pupils  normal.  The  voice  was  hoarse,  and  there  was  a 
frequent  ringing  cough.  At  the  top  of  the  sternum  was  a  round,  pul- 
sating tumor,  extending  down  to  within  i  inch  of  the  angle  of  Louis 
and  as  high  as  the  larynx.  It  was  3!  inches  wide  and  2  inches  high. 
It  was  tender  to  touch.     The  heart's  apex  extended  f  inch  outside  the 


h 


■r    ■ 

Ik 


/ 


Fig.  211. — Shape  of  head  and  suprasternal  bulge  in  Case  248. 

nipple,  in  the  fifth  space;  no  enlargement  to  the  right.  At  the  apex 
there  was  a  harsh  systolic  rnurmur,  transmitted  to  the  axilla.  Over 
the  tumor  a  harsh  systolic  was  also  heard.  About  the  tumor  there 
was  an  area  of  dulness,  as  shown  in  Fig.  212.  The  left  pulse  seemed 
a  Uttle  larger  than  the  right.  The  artery  walls  were  easily  felt. 
The  lungs  and  abdomen  were  negative  save  for  double  inguinal  hernia. 
A  laryngologic  examination  showed  paralysis  of  the  recurrent 
laryngeal  nerve.  Systolic  blood-pressure  at  entrance  was  155.  It 
soon  fell  to  130  mm.  Hg.,  and  remained  there  during  the  nine  months 
of  his  stay  in  the  hospital.    Blood  and  urine  showed  nothing  abnormal. 


HOARSENESS 


565 


There  was  ho  fever.  The  cough  was  controlled  only  by  |-gr.  doses  of 
codein  or  morphin.  X-ray  showed  a  shadow  corresponding  with  the 
ascending  and  transverse  arch  of  the  aorta.  A  diastolic  murmur  was 
audible  from  time  to  time,  usually  best  heard  at  the  apex,  but  also  in 
the  third  and  fourth  left  interspaces,  near  the  sternum.  Dr.  R.  H. 
Fitz  considered  it  due  to  mitral  stenosis.  It  could  be  heard  indis- 
tinctly as  far  back  as  the  posterior  axillary  line.  It  was  a  long,  early 
diastolic  sound  and  replaced  the  aortic  second  sound  at  the  apex. 


Fig.  212. — Physical  signs  in  Case  248. 


On  the  30th  of  January  250  c.c.  of  a  i  per  cent,  solution  of  gelatin 
in  0.6  per  cent,  sodium  chlorid  solution  were  injected  under  the  skin, 
on  the  left  side  of  the  abdomen.  This  caused  •  severe  pain  and  two 
hours  later  a  chill,  with  rise  of  temperature  to  102°  F.,  subsiding  in 
about  thirty-six  hours.  An  area  of  tenderness  and  redness  sur- 
rounded the  site  of  the  injection  and  extended  round  to  the  back. 
This  was  still  present  February  5th.  On  that  date  the  diastoUc  mur- 
mur in  the  left  anterior  axillary  line  was  louder  than  the  systolic. 


566  DIFFERENTIAL  DL\GNOSIS 

By  the  9th  of  February  the  local  reaction  about  the  site  of  the  gelatin 
injection  was  gone,  and  on  the  12th  of  February  a  second  injection, 
similar  to  the  first,  was  given.  The  reaction  was  like  that  after  the 
previous  injection,  but  somewhat  milder.  There  was  no  effect  per- 
ceived in  the  condition  of  the  tumor. 

Discussion. — When  hoarseness  and  cough  appear  in  a  middle- 
aged  man,  without  any  evidence  of  acute  infection  and  immediately 
following  an  attack  of  pain  about  the  upper  chest  and  shoulders  or 
in  the  arms,  one  should  always  suspect  that  aneurysm  is  the  cause. 
When  a  pulsating  tumor  appears  at  the  root  of  the  neck  in  front,  we 
can  have  very  little  doubt  of  the  diagnosis.  Such  a  tumor  might 
conceivably  be  a  pulsating  vascular  thyroid,  but  such  a  lesion  would 
certainly  have  been  of  much  longer  duration,  and  would,  in  all  prob- 
ability, be  associated  with  other  manifestations  of  thyrotoxicosis. 

If  the  patient  has  aneurysm,  as  there  is  every  reason  to  believe, 
the  diastolic  murmur  is  naturally  to  be  explained  as  a  result  of  widen- 
ing in  the  aortic  arch  at  the  base  of  the  aortic  cusps.  There  seems  no 
good  sense  in  calling  it  mitral  stenosis.  The  fact  that  the  patient  has 
been  treated  by  many  doctors  for  what  was  called  rheumatism  is  no 
reason  for  supposing  that  he  has  ever  had  rheumatism,  in  view  of  the 
fact  that  pains  often  mistaken  for  that  disease  are  especially  common 
in  aneurysm. 

The  ::t;-ray,  as  is  usual  in  such  cases,  showed  a  much  more  ex- 
tensive growth  within  the  thorax  than  would  have  been  predicted 
from  what  we  would  discover  on  direct  physical  examination.  The 
effects  of  gelatin  injections  in  this  case  were  similar  to  what  I 
have  seen  in  a  good  many  others  during  the  luckily  short-lived 
vogue  of  that  treatment.  It  causes  a  great  deal  of  pain,  but  no  good 
effect. 

Outcome. — The  patient's  general  condition  had  improved  very 
much  and  he  was  active  in  helping  about  the  ward.  On  the  24th  of 
February  he  left  the  hospital. 

Case  249 

An  Italian  schoolboy  of  nine  entered  the  hospital  March  i,  1909. 
Since  the  4th  of  July  the  boy  has  been  hoarse.  In  January  he  choked 
on  a  peanut.  Last  month  he  had  his  tonsils  removed.  Except  for 
hoarseness  he  is  now  all  right.  Family  history  and  past  history  nega- 
tive save  that  he  has  had  scabies. 

Physical  examination  showed  a  healthy  boy  with  inspiratory  and 
expiratory  dyspnea,  involving  movements  of  the  accessory  muscles  of 


HOARSENESS  567 

respiration.  Physical  examination  was  negative  save  as  relates  to 
the  larynx  and  the  fingers.     His  nails  were  somewhat  incurved. 

Discussion. — Probably  the  history  of  choking  on  a  peanut  and  the 
tonsillectomy  have  nothing  to  do  with  this  case,  as  six  months  have 
elapsed  since  the  choking  and  a  month  since  the  tonsillectomy.  Or- 
ganic disease  of  the  larynx  is  not  common  at  this  boy's  age,  but  his 
clubbed  fingers  suggest  that  some  congenital  cause  may  have  been  at 
work.     What  this  is  only  the  laryngoscope  can  determine. 

It  is  of  some  interest  to  note  that  although  the  cause  of  dyspnea 
is  high  up  in  the  respiratory  passages,  the  dyspnea  is  not  exclusively 
of  the  inspiratory  type,  but  involves  expiration  as  well.  We  are 
usually  taught  that  trouble  of  this  sort  should  produce  inspiratory, 
not  mixed,  dyspnea. 

Outcome. — Laryngoscopic  examination  showed  a  papilloma  of  the 
larynx.  On  the  4th  of  March  he  was  transferred  to  ward  G  for 
operation.  On  the  5th  of  March  the  papilloma  was  removed.  By 
the  8th  the  child  was  out  of  bed,  although  there  was  a  large  piece  of 
the  growth  still  remaining.     He  left  the  hospital  on  the  nth. 

Case  250 

A  salesman  of  fifty-six  entered  the  hospital  May  23,  1910.  Family 
history  not  remarkable.  The  patient  has  always  been  well,  but 
seven  years  ago  he  had  to  give  up  playing  baseball  because  he  could 
not  run  the  bases.  Five  years  ago  he  began  to  get  somewhat  more 
short  of  breath.  Three  years  ago  he  was  taken  rather  suddenly  with 
hoarseness  and  a  chill  and  pain  in  his  right  side  and  fever.  The  illness 
was  called  grip,  but  he  has  never  recovered  his  strength  and  has  never 
been  able  to  work  since  that  time.  He  lost  25  pounds  in  weight  at  the 
time  of  that  illness  and  25  pounds  more  since  that  time.  Any  at- 
tempt to  work  and  exert  himself  in  any  way  causes  a  choking  sense  of 
pressure  beneath  the  sternum,  a  short  dry  cough,  and  difficulty  in 
getting  his  breath.  He  has  had  no  sputum  and  no  pain,  no  wheez- 
iness,  and  no  paroxysms  of  dyspnea. 

For  three  years  he  has  had  left  trifacial  neuralgia,  the  pain  coming 
in  quick  flashes  and  going  from  the  left  temple  to  the  corner  of  the 
mouth.     Throughout  the  three  years  he  has  continued  to  he  hoarse. 

The  patient  is  well  nourished  and  lies  comfortably  without  pil- 
lows. Pupils  negative.  Knee-jerks  and  Achilles'  jerks  not  obtained. 
Babinski's  reaction  is  present  on  the  left.  The  right  plantar  is  not 
satisfactorily  obtained.  There  is  no  glandular  enlargement.  The 
heart  is  negative.    Lungs  as  in  Figs.  213,  214.    The  breathing  seems  to 


568 


DIFFERENTIAL   DIAGNOSIS 


be  of  diminished  intensity  over  the  whole  left  side.  The  right  pulse  is 
stronger  than  the  left.  Abdomen  negative.  The  laryngoscope  shows 
that  the  lower  part  of  the  trachea  is  pushed  forward  so  that  the  tube 
is  not  straight.  Blood  and  urine  are  normal,  likewise  Wassermann 
reaction. 

Discussion. — Tuberculosis,  syphilis,  and  tumor  must  be  con- 
sidered. The  lung  signs  and  the  hoarseness  are  familiar  tuberculous 
symptoms.  Loss  of  weight  would  be  a  natural  accompaniment. 
Against  this  idea,  however,  is  the  fact  that  his  illness  began  with 


Fig.  213. — Chest  signs  in  Case  250. 


hoarseness  and  the  cough  developed  considerably  later  and  seems 
to  be  directly  connected  with  exhaustion.  Without  the  finding  of 
bacilli  or  other  very  positive  .evidences  of  tuberculosis  there  would  be 
no  reason  to  consider  this  disease  further,  in  view  of  the  many  symp- 
toms pointing  in  another  direction. 

Syphilis,  with  resulting  aneurysm,  naturally  occurs  to  us  when 
we  find  that  the  knee-jerks  are  absent  and  recognize  symptoms  like 
those  of  mediastinal  pressure,  especially  the  displacement  of  the 
trachea.  The  negative  Wassermann  reaction  does  not  disprove  this 
theory.     On  the  other  hand,  we  have  no  positive  evidence  of  syphilis, 


HOARSENESS 


569 


and  the  pain  which  the  patient  has  suffered  is  not  like  that  generally 
seen  in  aneurysm.  The  diminution  of  the  left  pulse  and  the  respira- 
tion in  the  left  lung  could  be  explained  either  by  aneurysm  or  by  some 
other  cause  of  pressure.  If  the  statement  of  a  displacement  from 
behind  forward  is  correct,  we  must  recognize  that  this  is  not  the  usual 
direction  in  which  aneurysm  exerts  its  pressure  upon  the  trachea. 
Aneurysm  generally  presses  upon  the  front  or  side  of  the  windpipe. 

Further  evidence  in  the  difficult  distinction  between  mediastinal 
tumor  and  aneurysm  must  be  sought  in  x-ray  examination. 

Outcome. — During  a  month's  stay  in  the  hospital  the  patient  lost 
10  pounds  in  weight,  but  had  no  fever.     Systolic  blood-pressure,  122. 


Fig.  214. — Chest  signs  in  Case  250. 

X-ray  showed  large  indefinite  shadow  in  the  mediastinum,  believed  by 
Dr.  Dodd  to  show  definite  evidence  of  mediastinal  pressure,  especially 
on  the  right  of  the  sternum.  Skin  tuberculin  test  was  negative,  and 
subcutaneous  tuberculin,  gradually  increased  i  to  10  mg.,  also  gave  no 
reaction.  On  the  nth  of  June  the  lung  signs  were  less  marked  behind, 
but  the  crackles  in  the  upper  fronts  persisted.  He  was  given  treat- 
ments by  x-r&y,  and  left  the  hospital  on  the  i6th  of  June.  He  died 
October  9,  1912.     The  death  certificate  was  signed  "Heart  trouble." 


570  DIFFERENTIAL  DLA.GNOSIS 

Case  251 

A  fanner  of  twenty  entered  the  hospital  August  8,  1910.  The 
patient  was  born  in  Russia,  and  had  been  studied  in  the  Out-patient 
Department  previous  to  entrance.  He  spoke  but  Httle  EngHsh,  and 
all  the  history  that  could  be  obtained  was  that  he  had  had  pains  in 
his  ankles,  shoulders,  elbows,  and  wrists  three  months  ago  and  that 
for  the  past  month  he  had  been  very  hoarse,  but  had  been  able  to  work. 

Physical  examination  showed  good  nutrition,  normal  pupils  and 
reflexes,  no  glandular  enlargement.     The  heart's  impulse,  seen  and 


Fig.  215. — Position  of  .T-ray  shadows  in  Case  251. 

felt  in  the  sixth  space,  3  cm.  outside  the  nipple  Kne,  right  border  4^ 
cm.  from  midsternum.  There  was  a  palpable  systolic  thrill  at  the 
apex  and  a  blowing  systoKc  murmur  transmitted  to  the  axilla  and  base. 
A  rough  diastolic  murmur  was  heard  best  in  the  axilla  and  at  the  apex, 
faintly  along  the  left  edge  of  the  sternum,  not  at  all  on  the  right 
side.  The  aortic  second  was  faint;  pulmonic  second,  loud.  The  pulses 
had  a  marked  Corrigan  quality  and  there  was  a  capillary  pulse  visible 
in  the  fingers.  Duroziez's  sign  was  present  and  all  the  peripheral 
arteries  pulsated  visibly.  The  abdomen  was  negative,  save  that  the 
edge  of  the  liver  could  be  distinctly  felt  2  cm.  below  the  costal  margin. 
The  blood   and   urine   show'ed   nothing   abnormal.     Blood-pressure, 


HOARSENESS  57 1 

120  mm.  Hg.,  systolic;  40  mm.  Hg.,  diastolic.  Wassermann  reac- 
tion negative.     Skin  tuberculin  reaction  slightly  positive. 

Laryngoscopic  examination  showed  the  left  vocal  cord  in  the 
cadaveric  position,  both  in  respiration  and  phonation.  By  the  13th 
his  bronchitis  had  practically  cleared  up.  X-ray  on  the  i8th  showed  a 
shadow  about  the  roots  of  both  lungs,  especially  on  the  right.  Tuber- 
culous glands  and  malignant  disease  were  suggested  (Fig.  215).  The 
heart  by  rc-ray  was  huge.  The  patient  did  not  react  to  10  mg.  of  old 
tuberculin,  subcutaneously.  On  the  4th  of  September  the  right  border 
extended  4  cm.  beyond  the  right  edge  of  the  sternum,  in  the  third  space. 

Discussion. — Everything  points  toward  aneurysm  here  except 
the  negative  x-ray  examination  and  the  negative  Wassermann. 
It  is,  however,  possible  that  a  rheumatic  endocarditis  may  produce 
sufficient  dilatation  of  the  left  auricle  to  compress  or  injure  the  recur- 
rent laryngeal  nerve. 

The  cardiac  signs  do  not  indicate  anything  of  this  sort,  but  these 
signs  may  well  be  wrongly  observed  or  wrongly  interpreted. 

Despite  the  slightly  positive  skin  reaction  from  tuberculin  and 
the  shadows  about  the  roots  of  both  lungs,  there  seems  to  me  no 
good  reason  to  imagine  that  tuberculosis  is  the  cause  of  any  symptoms 
in  this  case.  The  negative  reaction  to  10  minims  of  old  tuberculin 
subcutaneously  is  important  negative  evidence  in  this  connection. 
I  do  not  see  how  a  positive  diagnosis  can  be  made.  On  the  whole,  I 
am  inclined  to  believe  that  syphilis  is  at  the  bottom  of  the  whole 
trouble.  So  large  a  heart  as  the  x-ray  shows  could  hardly  have  been 
produced  by  a  rheumatic  endocarditis  within  three  months  and 
without  more  evidence  of  decompensation.  It  seems  unreasonable  to 
suppose  that  a  dilated  left  auricle  has  produced  the  laryngeal  paralysis. 
I  believe  that  later  evidence  will  be  more  conclusive  in  favor  of  the 
diagnosis  of  aneurysm. 

Outcome. — Under  mercurial  inunction  and  iodid  of  potash  the 
patient  improved  very  much,  and  left  the  hospital  on  the  9th  of 
September,  having  gained  4  pounds  during  his  month's  stay. 

Case  252 

An  engineer  of  twenty-eight  entered  the  hospital  August  27,  19 10. 
The  patient's  family  history  is  negative.  For  two  years  he  has  had 
gaseous  indigestion  after  eating,  immediately  reheved  by  soda  or  any 
simple  remedy.  During  this  period  his  bowels  have  been  rather  con- 
stipated. He  denies  venereal  disease  and  has  always  considered  him- 
self well.     He  has  been  married  twelve  years.     He  has  no  children. 


572  DIFFERENTIAL   DIAGNOSIS 

In  January,  1908,  he  noticed  that  he  was  short  of  breath  on  exer- 
tion. This  trouble  has  steadily  and  slowly  increased  since.  Shortly 
after  this  he  noticed  a  pain  in  the  left  axilla — sharp,  stinging,  contin- 
uous— often  keeping  him  awake  at  night  during  the  six  months  of  its 
duration.  It  then  passed  off  spontaneously  and  did  not  recur.  For  a 
year,  however,  he  has  had  another  pain,  which  he  says  is  around  his 
heart,  passing  from  the  left  to  the  right  side,  sharp,  steady,  and  often 
preventing  sleep.  For  a  month  he  has  had  dry  cough  and  for  two 
weeks  orthopnea. 

Six  days  ago  lie  suddenly  became  hoarse,  and  has  been  unable  to 
speak  above  a  whisper  ever  since.  He  gave  up  work  ten  days  ago 
and  has  lost  much  in  weight  and  strength.  His  main  complaints  are 
dyspnea,  pain,  and  hoarseness. 

Physical  examination  showed  good  nutrition,  pupils,  glands,  and 
reflexes  normal.  The  whole  chest,  especially  the  left  chest,  heaved 
with  each  systole.  The  heart's  apex  reached  2^  cm.  outside  the  nipple 
hne  and  its  dulness  4^  cm.  to  the  right  of  midsternum.  The  quality 
of  the  impulse  was  forcible,  and  the  first  sound  was  followed  by  a  blow- 
ing systolic  murmur,  loudest  in  the  pulmonary  area.  The  pulmonic 
second  sound  was  palpable  as  a  shock  and  very  loud.  There  was  no 
thrill.  The  pulses  were  normal.  The  entire  left  lung  showed  broncho- 
vesicular  breathing  and  increased  whisper  and  was  nearly  flat  on  per- 
cussion. The  right  lung  was  normal,  likewise  the  abdomen.  Systolic 
blood-pressure  was  100  mm.  Hg.  in  the  right  arm,  90  in  the  left.  The 
blood  was  normal.  The  Wassermann  reaction  was  negative.  Urine 
was  normal.  A  laryngologist  found  the  left  vocal  cord  motionless  in 
the  cadaveric  position.  X-ray  showed  a  diffuse  shadow  through  the 
entire  left  chest,  suggesting  fluid  or  thickened  pleura.  No  evidence  of 
aneurysm.  On  the  ist  of  September  the  pupils  were  found  to  be 
unequal,  and  small,  hard,  epitrochlear  glands  were  felt. 

Discussion. — I  am  driven  to  a  similar  course  of  reasoning  in  this 
case  as  in  the  previous  one.  If  the  patient  has  no  syphilis,  why  should 
his  heart  be  so  large?  He  has  nothing  else  in  his  history  or  in  his 
physical  examination  to  produce  a  cor  bovinum  capable  of  lifting 
the  whole  chest  at  each  beat.  The  negative  a"-ray  does  not  disprove 
aneurysm,  for  the  extensive  shadow  in  the  left  chest  might  cover  up 
the  outline  of  the  aorta.  Just  what  is  going  on  in  the  left  chest  it  is 
difficult  to  say,  but  it  is  certainly  possible  that  aneursymal  pressure 
could  produce  such  appearances  and  signs.  Conceivably  a  chronic 
pleurisy  might  involve  the  recurrent  laryngeal  nerve  and  produce 
hoarseness;    or  syphiHs  of  the  lung  might  do  the  same  thing,  but 


HOARSENESS  573 

neither  of  these  diseases  can  account  for  so  large  and  forcible  a  heart, 
nor  for  two  weeks  of  orthopnea,  though  either  of  them  would  explain 
the  left  axillary  pain.  The  differences  in  the  pulses  and  pupils  and 
the  small,  hard  epitrochlear  gland  furnish  a  certain  amount  of  evidence 
confirmatory  of  the  diagnosis  of  syphilis  and,  therefore,  of  aneurysm. 
Outcome. — On  September  ist  the  left  chest  was  tapped,  but  no 
fluid  obtained,  the  needle  evidently  entering  the  lung.  Under  rest 
in  bed,  with  potassium  iodid,  20  gr.  after  meals,  and  an  occasional 
dose  of  morphin,  the  patient's  pain  practically  disappeared  and  he  had 
good  nights.     On  the  7th  he  left  the  hospital. 

Case  253 

A  housewife  of  thirty-seven  entered  the  hospital  January  9,  191 2. 
The  patient's  family  history  was  negative.  She  had  a  peritonsillar 
abscess  seven  years  ago.  Two  years  ago  she  was  struck  in  the  right 
breast  and  on  the  head  in  a  street-car  accident.  After  that  she  had 
nausea  and  fainting  spells  in  the  morning,  at  first  three  or  four  times 
a  week,  less  frequently  after  that,  but  she  still  has  them  every  month 
or  two.  In  August,  191 1,  she  became  hoarse  and  this  symptom  has 
persisted  ever  since.  Three  months  ago  she  caught  cold,  but  both  this 
and  the  hoarseness  cleared  up  after  a  two  weeks'  vacation.  Two  and 
a  half  months  ago  the  hoarseness  returned,  and  she  has  had  much 
treatment  for  her  throat  without  rehef.  When  asleep  her  breathing 
is  noisy  and  often  wakes  her.     She  has  no  sore  throat  and  no  cough. 

A  month  ago  her  breathing  became  labored  on  exertion,  though  she 
could  still  He  flat.  A  week  ago  she  took  to  her  bed  from  exhaustion. 
Three  days  ago  she  awoke  at  3  o'clock  in  the  morning  with  extreme 
dyspnea,  which  lasted  several  hours.  Since  that  time  she  has  never 
been  free  from  dyspnea  of  some  degree,  and  has  had  recurring  attacks 
in  which  she  had  to  fight  for  breath.  These  attacks  come  more  fre- 
quently at  night,  and  last  from  one-half  to  three  hours.  She  has  lost 
much  sleep  and  much  weight  in  the  last  week. 

Physical  examination  showed  good  nutrition,  nlarked  expiratory 
dyspnea,  and  moderate  inspiratory  dyspnea.  Pupils  and  reflexes 
negative.  No  enlarged  glands,  tongue  clean.  Wassermann  reaction 
moderately  positive.  Larynx  showed  slight  swelKng  of  the  glottis 
with  reddening.  On  the  inside  of  the  larynx  the  tissues  on  both  sides 
showed  swelling,  which  ran  up  upon  the  two  vocal  cords.  The  cords 
were  almost  approximated,  were  motionless,  and  their  edges  showed 
ragged  ulcers.  On  the  loth  tracheotomy  had  to  be  done.  The  patient 
was  given  "606,"  mercury,  and  iodid  of  potash,  but  the  mercury  was 


574 


DIFFERENTIAL  DIAGNOSIS 


omitted  after  a  few  days  because  of  stomatitis.  The  patient  rapidly 
and  steadily  improved  and  by  the  i8th  could  speak  aloud.  On  the 
29th  she  got  her  second  dose  of  "606,"  and  on  the  5th  of  February  the 
tube  was  removed.  The  course  of  the  temperature  is  shown  in  Fig.  216. 
The  leukocytes  at  entrance  were  14,500;  on  the  17th,  13,000;  on  the 
24tli,  10,000.     The  blood-pressure  was  160  mm.  Hg.,  systolic. 

Discussion. — When  hoarseness  has  lasted  for  six  months,  although 
with  a  slight  intermission  in  the  middle  of  that  period,  we  may  be  sure 
that  some  serious  organic  disease  is  present.  We  have  no  evidence  of 
a  mediastinal  pressure,  and  attention  is,  therefore,  naturally  concen- 


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trated  upon  the  local  condition  of  the  larynx  itself.  With  a  positive 
Wassermann  reaction  we  may  certainly  expect  that  syphihtic  changes 
will  be  found  there,  especially  as  acute  suffocative  attacks  are  par- 
ticularly common  in  laryngeal  syphilis.  In  this,  as  in  one  previous 
case,  I  am  interested  to  note  that  the  dyspnea  was  not  of  the  inflam- 
matory but  of  the  mixed  type,  contrary  to  tradition. 

The  brilliant  effects  of  salvarsan  have  seldom  been  more  impressed 
upon  me  than  in  this  case.  A  patient  whose  life  was  in  serious  danger 
was  almost  well  in  a  week  after  its  use. 

Outcome. — February  6,  19 12,  she  went  home,  apparently  cured. 
In  January,  1913,  she  reported  herself  as  well,  except  for  some  dysp- 
nea on  exertion.     No  hoarseness. 


CHAPTER  XIV 

PALLOR 

As  a  rule,  pallor  is  not  due  to  anemia.  Pale  people  are  common; 
anemia  is  rare.  The  majority  of  cases  of  non-anemic  pallor  are  due 
to  living  indoors,  to  continuous  exposure  to  high  temperatures,  as  in 
industry  or  in  the  tropics,  or  to  congenital  causes. 

Tuberculous  patients  are  usually  pale,  but  seldom  anemic.  Even 
extreme  and  ghastly  pallor  in  consumption  may  be  accompanied  by 
a  normal  blood. 

What  the  Germans  call  the  "cachexia  of  old  age"  is  a  state  in  which 
pallor  as  well  as  emaciation  forms  a  part.  It  is  reasonable  to  suppose 
that  such  pallor  is  due  to  changes  in  the  cutaneous  circulation.  Pre- 
sumably the  same  is  true  of  the  pallor  resulting  from  exposure  to  heat 
or  from  living  indoors. 

Pallor  of  the  lips  is  much  more  significant  than  pallor  of  the  face, 
much  more  apt  to  mean  anemia,  yet  even  this  site  is  by  no  means  proof 
of  anemia.  Any  one  who  is  in  the  habit  of  basing  his  judgment  upon 
the  looks  of  the  skin  and  mucous  membrane  has  violent  surprises 
awaiting  him. 

Edematous  or  myxedematous  skin  is  usually  pale,  whether  there  is 
anemia  behind  it  or  not. 

A  yellow  pallor  is  probably  more  common  in  pernicious  anemia 
than  in  any  other  single  disease,  but  it  is  especially  the  combination 
of  such  a  tint  with  good  nutrition  that  is  properly  suggestive  of  perni- 
cious anemia.  When  accompanied  by  emaciation,  precisely  the  same 
yellow  tint  results  from  secondary  anemias,  however  produced.  On 
the  other  hand,  it  must  never  be  forgotten  that  pernicious  anemia  may 
cause  no  pallor  at  all. 

Case  254 

A  housewife  of  fifty-one  entered  the  hospital  May  31,  191 2.  Her 
family  history  and  past  history  are  not  of  importance.  The  patient 
passed  the  menopause  eleven  years  ago.  For  three  years  she  has  been 
troubled  by  gas  in  the  stomach  and  sHght  discomfort  when  the  organ 
is  empty.  She  is  always  relieved  by  food.  Her  appetite  and  digestion 
seem  to  be  good. 

575 


576  DIFFERENTIAL   DIAGNOSIS 

Except  for  this  trouble  she  has  called  herself  well  until  five  months 
ago,  when  she  began  to  notice  pallor  and  loss  of  weight  and  strength. 
The  hunger  pain  became  worse,  sharp  and  burning  in  character. 
The  epigastrium  was  tender.  The  pain  was  aggravated  by  soda, 
relieved  by  food  or  by  vomiting.  The  vomitus  has  never  been  bloody 
nor  resembled  coffee-grounds.  She  was  in  the  Boston  City  Hospital 
from  March  27th  to  April  18,  1912.  She  was  fed  on  milk  and  lime- 
water  and  told  that  she  had  gastric  ulcer.  For  several  weeks  previous 
to  this  time  she  was  treated  there  as  an  out-patient.  She  was  much 
relieved  by  this  stay  in  the  Boston  City  Hospital,  and  on  discharge 
went  back  to  work  and  resumed  her  ordinary  diet,  but  continued  to 
lose  ground  slowly,  and  for  the  last  two  weeks  has  been  much  worse, 
though  she  has  kept  at  work.  Last  night  she  vomited  many  times, 
though  she  has  not  previously  done  so  since  leaving  the  Boston  City 
Hospital.  Her  appetite  is  notably  good;  her  bowels  move  three  or 
four  times  a  day.  She  has  noticed  slight  swelling  of  her  feet  and 
under  her  eyes.  She  has  no  nocturia  or  jaundice.  Any  kind  of 
food  relieves  the  pain  for  a  time,  but  it  always  returns,  regardless 
of  diet. 

On  physical  examination,  she  is  well  nourished,  does  not  look 
sick,  except  that  her  skin  is  very  pale  with  a  slightly  yellowish  tinge. 
Pupils,  glands,  and  reflexes  normal.  Heart's  impulse  extends  2  cm. 
outside  the  nipple  line,  and  is  accompanied  by  a  systolic  murmur 
audible  all  over  the  precordia  and  transmitted  to  the  axilla,  but  not 
replacing  the  first  sound.  Pulmonic  second  is  accentuated.  Blood- 
pressure,  115  mm.  Hg.,  systolic;  60  mm.  Hg.,  diastolic.  Abdomen  is 
negative.  There  is  no  edema.  The  urine  is  negative.  Weight,  109I 
pounds,  without  clothes.  Stomach-tube  examination  shows  small 
amount  of  food  in  the  fasting  stomach.  After  a  test-meal  HCl  was 
absent.  On  the  5th  of  June  slow  rhythmic  peristalsis,  from  left  to 
right,  corresponding  in  time  to  that  of  a  normal  stomach,  was  observed 
in  the  epigastrium.  She  complained  of  no  pain  and  practically  of  no 
digestive  disturbance.  The  guaiac  test  in  the  stools  was  positive  June 
4th,  6th,  7th,  13th,  i8th,  and  2 2d.  The  amount  of  blood  in  the  feces 
seemed  to  be  considerable.  June  loth  the  left  leg  became  swollen 
and  tender,  and  a  hard,  cordy  vein  was  felt  in  the  region  of  the  internal 
saphenous.  On  the  2 2d  a  hard,  smooth  lump,  movable  laterally  and 
with  respiration,  not  tender,  was  felt  midway  between  the  ensiform 
and  the  navel. 

Up  to  the  time  of  her  discharge,  July  8th,  there  was  almost  no 
change  in  her  condition.     The  phlebitis  subsided  in  the  left  leg  and 


PALLOR  577 

was  followed  by  a  similar  infection  in  the  right.  Loss  of  appetite 
and  moderate  distress  after  meals  were  not  present  after  June  loth, 
when  we  began  to  give  her  a  dilute  hydrochloric  acid,  lo  drops  after 
meals.  The  improvement  was  prompt  and  striking.  On  the  other  hand, 
the  blood  showed  little  improvement.  Red  cells  at  entrance,  2,500,000; 
July  5th  they  were  still  below  3,000,000,  though  the  hemoglobin  had 
risen  from  40  per  cent.  June  7th  to  50  per  cent.  July  5th.  The  leuko- 
cytes ranged  from  6000  to  10,000.  The  differential  count  was  normal. 
The  stained  smear  showed  always  very  marked  achromia,  great  varia- 
tions in  size  and  shape,  no  stippling  or  nucleated  red  cells,  a  dimin- 
ished number  of  blood-plates,  and  some  macrocytosis.  Bismuth 
:r-ray  of  the  stomach  showed  in  all  the  plates  a  defect  in  the  outline 
of  greater  curvature. 

She  re-entered  September  4th,  having  been  fairly  comfortable 
and  able  to  do  her  work  since  leaving  in  July.  She  has  now  a  good 
appetite  and  has  gained  in  weight  and  color.  She  has  no  pain,  but 
constant  eructations  of  gas  and  constant  nausea.  Diet  makes  no 
difference.  When  she  lies  on  her  right  side  she  is  troubled  by  a  drag- 
ging sensation  in  the  epigastrium.  The  past  two  weeks  her  wrists  and 
some  of  the  joints  have  been  swollen  and  painful.  The  mass  was 
made  out  as  before  in  the  abdomen. 

She  refused  operation  and  left  the  hospital  on  the  7th  of  Septem- 
ber, but  entered  for  the  third  time,  September  24th.  This  time  the 
curved  edge  of  a  mass,  firm,  not  fluctuant  and  not  moving  with 
respiration,  was  felt  in  the  lower  epigastric  region,  a  little  to  the  left 
of  the  median  line.  Last  December  she  weighed  129  pounds.  Be- 
tween this  and  the  following  May  she  lost  2 1  pounds ;  since  then  she 
has  held  her  weight. 

Discussion. — Three  years  of  stomach  trouble  of  the  type  that  is 
relieved  by  food,  and  accompanied  by  good  appetite,  strongly  in- 
clines us  to  make  a  snap  diagnosis  of  peptic  ulcer,  gastric  or  duodenal. 
The  present  condition  of  good  nutrition,  despite  some  marked  pallor, 
supports  this  idea. 

On  the  other  hand,  the  presence  of  stasis,  achylia,  and  especially 
the  visible  peristalsis  in  the  epigastrium,  inclines  us  to  interpret  the 
lump  which  later  appeared  as  cancer  rather  than  as  perigastric  exudate 
surrounding  an  ulcer. 

When  the  patient  gained  so  markedly  after  leaving  the  hospital 
we  were  again  in  doubt,  but  the  mass  felt  at  the  time  of  the  second 
entrance  was  strongly  like  that  produced  by  gastric  cancer. 

Pernicious  anemia  was  at  the  time  seriously  considered,  but  this 

Vol.  11—37 


578 


DIFFERENTIAL  DIAGNOSIS 


was  a  blunder,  for  the  very  marked  achromia  should  have  prevented 
our  wasting  any  time  in  the  consideration  of  that  disease. 

Outcome. — On  the  27th  of  September  Dr.  F.  T.  Lord  thought  the 
diagnosis  to  be  carcinoma  of  the  lesser  curvature  of  the  stomach, 
but  thought  there  was  a  reasonable  doubt  in  favor  of  gastric  ulcer. 
Accordingly,  on  the  28th,  Dr.  Scudder  opened  the  abdomen  and  found 
a  hard  mass,  size  of  the  fist,  involving  the  greater  curvature  and  an- 
terior wall  of  the  stomach.  No  metastases  palpable.  Nothing  done. 
The  patient  recovered  promptly  from  the  operation  and  left  the  hos- 
pital on  the  9th  of  October,  191 2.  She  reported  February  17,  19 13, 
that  she  was  losing  ground  steadily  and  could  take  only  milk. 

Case  255 

A  blacksmith  of  fifty-one  entered  the  hospital  October  8,  1907. 
For  the  past  six  months  the  patient  has  noticed  pallor,  dyspnea  on 
exertion,  gradual  loss  of  weight  and  strength.     He  has  lost  30  pounds 

in  six  months.  For  three  months  he  has 
been  unable  to  work.  During  the  past 
two  weeks  he  has  had  for  the  first  time 
some  vomiting  spells,  three  in  number, 
food  only  being  rejected.  There  is  some 
dull  pain  in  the  right  hypochondrium,  no 
jaundice,  no  cough  or  edema.  His  family 
history,  previous  history,  and  habits  are 
excellent,  except  that  he  takes  an  excess- 
ive amount  of  tobacco.  He  denies  vene- 
real disease. 

Physical  examination  shows  poor  nutri- 
tion, marked  pallor.  The  heart's  impulse 
is  in  the  fourth  interspace,  i^  inch  outside 
the  left  nipple,  no  enlargement  to  the  right. 
Just  inside  the  apex  there  is  a  rough  pre- 
systolic murmur  and  thrill,  ending  in  a 
short,  sharp  first  sound ;  on  the  left  border 
of  the  sternum  a  faint  diastolic  murmur; 
at  that  situation  and  at  the  apex  a  rough,  loud  systolic  murmur. 
The  pulse  has  a  Corrigan  quality.  The  lungs  are  normal  save  for  a 
few  crackles  at  the  bases.  Abdomen  and  extremities  negative. 
Temperature  as  seen  in  Fig.  217.  Urine  negative.  The  blood  shows 
red  cells,  1,216,000;  white  cells,  7000;  hemoglobin,  35  per  cent.  Stained 
specimen  shows  polynuclears,  58.5  per  cent.;  lymphocytes,  41.5  per 


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Fig.  217. — Chart  of  Case  255. 


PALLOR  579 

cent.;  slight  achromia  and  deformities,  no  abnormal  staining,  no 
blasts.  Blood-plates  diminished.  SystoHc  blood-pressure,  128.  On 
the  15th  the  blood  showed  red  cells,  800,000;  white,  12,900;  poly- 
nuclears,  56  per  cent.;  lymphocytes,  44  per  cent.,  many  of  them  of 
the  large  type  with  azur  granules.  On  the  17th  the  white  cells  were 
29,000;  polynuclears,  36  per  cent.;  large  lymphocytes,  59  per  cent.; 
small  lymphocytes,  5  per  cent.;  12  normoblasts  and  3  megaloblasts 
were  seen  while  counting  200  cells. 

Discussion.^ — The  history  gives  us  no  inkling  of  what  the  patient's 
pallor  may  be  due  to.  His  excess  in  tobacco  has  certainly  no  par- 
ticular significance,  and  I  may  here  confess  that  I  have  seldom  if 
ever  been  convinced  that  excess  in  tobacco  is  in  itself  the  cause  of  any 
serious  symptom,  whether  cardiac,  digestive,  or  nervous.  Excess  is 
as  apt  to  be  a  result  of  nervous  conditions  as  their  cause.  Doubt- 
less it  does  some  harm  to  some  people,  but  I  find  it  difficult  to  formu- 
late any  definite  beliefs  as  to  its  injurious  action  on  the  majority  of 
smokers,  even  of  excessive  smokers. 

The  present  condition  of  the  heart  might  be  due  either  to  syphilitic 
or  to  rheumatic  disease  of  that  organ.  In  the  absence  of  any  rheumatic 
history,  syphilis  is  perhaps  more  probable,  but,  in  view  of  the  very 
grave  anemia  shown  by  the  blood  examination,  it  is  our  first  business 
to  determine,  if  possible,  what  can  be  inferred  from  the  blood  itself. 

Could  syphilis  produce  this  condition?  Very  grave  anemias  have 
often  been  attributed  to  syphiKs,  doubtless  rightly  in  some  cases, 
but  such  anemias  have  been,  so  far  as  I  know,  invariably  consequent 
upon  long-standing,  obvious,  and  virulent  syphiUtic  lesions.  We  have 
nothing  of  the  kind  here.  Moreover,  we  have  a  fever  of  a  type  not 
often  seen  in  the  later  stages  of  S3^hins  when  grave  anemias  may 
develop.  A  close  study  of  the  leukocytes  leaves  me  entirely  con- 
vinced that  the  patient  suffered  from  an  acute  lymphoblastoma  with 
l3anphemia.  The  excess  of  white  cells  is  not  great,  but  I  know  of  no 
disease  other  than  that  just  mentioned  which  can  produce  such  a 
differential  count  in  connection  with  such  a  total  leukocyte  count. 
Moreover,  the  insidious  development  of  anemia  is  especially  charac- 
teristic of  the  l3rmphoblastomous  lesions  of  this  t3rpe.  Pallor  and  the 
general  symptoms  of  anemia  are  often  the  patient's  first  complaint. 
This  means  that  the  red  cells  and  the  red  cell-forming  tissue  of  the 
marrow  have  been  crowded  out  by  the  overgrowth  of  marrow  lympho- 
cytes, and  that  the  anemia  is  of  the  myelophthisic  type. 

Outcome. — The  patient  lost  steadily  in  strength,  and  died  on  the 
19th  of  October.    No  autopsy. 


580  DIFFERENTIAL   DIAGNOSIS 

Case  256 

A  maid  of  twenty-three  entered  the  hospital  January  11,  1910. 
The  patient's  family  history  and  past  history  are  good,  except  that 
she  had  rheumatic  fever  at  fourteen  and  a  year  ago  "used  to  vomit 
blood."  Her  menstruation  is  not  regular,  a  month  or  more  being 
often  omitted. 

For  two  months  she  has  been  getting  pale  and  weak.  Two  or 
three  times  a  week  she  has  severe  headaches  and  is  very  nervous. 
For  the  last  four  days  she  has  had  a  smothering  sensation  in  her 
upper  chest,  and  for  two  months  has  been  short  of  breath  on  ex- 
ertion. In  all  her  attacks  she  has  vomited  but  once  and  has  had  ahnost 
no  pain.  Appetite,  bowels,  and  sleep  are  normal.  She  thinks  she  has 
lost  a  good  deal  of  weight. 

Physical  examination  shows  good  nutrition,  pallor,  and  slight  yel- 
lowness of  the  skin  and  mucous  membranes.  Chest  negative,  save 
for  a  slight  systolic  murmur,  limited  to  the  apex  of  the  heart  and  the 
region  of  the  left  third  costal  cartilage.  Abdomen  and  extremities 
negative.  Two  examinations  of  stools  showed  nothing  abnormal. 
Red  cells  numbered  4,280,000  and  continued  near  that  point  during 
her  three  weeks'  stay  in  the  hospital.  Hemoglobin  at  entrance  was 
45  per  cent. ;  it  never  rose  above  50  per  cent,  during  the  period  of  ob- 
servation. The  leukocytes  showed  nothing  abnormal.  In  the  stained 
specimen  there  was  marked  achromia,  slight  variations  in  size  and 
shape.  No  abnormal  staining,  no  nucleated  red  cells.  The  patient 
had  no  fever  and  a  negative  urine  during  her  three  weeks'  stay. 
She  was  given  at  first  Blaud's  pills,  10  gr.,  three  times  a  day. 
Later,  15  minims  of  the  green  citrate  of  iron  was  given  her  subcu- 
taneously  every  other  day.  She  improved  markedly  in  looks  and 
feelings  despite  the  absence  of  much  change  in  the  blood. 

Discussion. — I  have  to  drop  out  of  account  altogether,  in  the 
diagnosis  of  this  case,  the  rheumatic  fever  and  the  statement  that 
she  "used  to  vomit  blood."  Both  may  be  true,  but  I  can  make  noth- 
ing of  them  and  find  no  present  results  of  them  in  the  patient. 

What  we  now  see  is  that  she  has  shown  the  general  symptoms  of 
anemia  for  two  months,  and  has  now  a  yellow  pallor  and  a  notably 
low  hemoglobin.  With  a  history  of  rheumatic  fever  one  looks,  of 
course,  for  evidence  of  endocarditis,  for  that  infection  often  accom- 
panies or  causes  anemia;  but,  with  no  fever  and  no  more  definite 
cardiac  signs,  I  cannot  believe  that  there  is  any  active  endocarditis 
in  this  case.     Pretty  much  everybody  has  sooner  or  later  a  slight 


PALLOR  581 

systolic  murmur  like  that  here  described.  The  more  often  one  listens 
.for  it  and  the  more  carefully,  the  more  frequently  it  appears  upon  our 
records.  Its  absence  is  surprising  in  careful  bedside  notes  of  any 
patient  who  is  sick  enough  to  call  a  doctor. 

Insidious  symptoms  of  this  type  in  a  girl  of  twenty-three  always 
makes  us  look  with  special  care  for  evidence  of  pulmonary  tubercu- 
losis. I  cannot  positively  deny  the  possibility  of  tuberculosis  in  this 
case,  but,  despite  painstaking  search,  no  evidence  of  it  could  be  found. 

The  remaining  probability,  chlorosis,  has  of  late  years  become  a 
rarity  in  our  clinics,  so  that  one  hesitates  much  more  than  formerly 
to  make  such  a  diagnosis.  Nevertheless,  it  will  account  for  all  the 
facts  here  presented  and  is  the  best  working  hypothesis  in  sight. 

Outcome. — On  the  30th  of  January,  19 10,  she  left  the  hospital. 
May  I,  1913,  she  reported  herself  well  and  at  work. 

Case  257 

A  waist  maker  of  forty,  born  in  Russia,  entered  the  hospital 
February  12,  1910.  The  patient  was  sent  in  from  the  Out-patient 
Department  on  account  of  excessive  uterine  flowing.  Her  father  was 
killed  in  the  Odessa  massacre.  Her  family  history  is  not  otherwise 
remarkable.  She  has  had  no  previous  illness  of  note.  Her  menstrua- 
tion has  been  regular,  but  always  excessive.  It  has  been  no  more  so 
of  late.  Late  in  December,  1909,  she  got  pale  and  lost  her  appetite; 
in  consequence  she  ate  very  irregularly  and  meagerly.  At  this  time 
she  began  to  have  pain  in  her  chest  and  between  her  shoulders.  For 
the  past  two  weeks  she  has  had  palpitation.  She  stopped  work 
five  days  ago  on  account  of  increasing  weakness.  Yesterday  her 
menstruation  began,  a  week  ahead  of  time,  accompanied  by  headache. 
She  has  constant  pain  in  the  middle  and  right  side  of  her  chest.  In 
the  last  two  years  she  has  lost  17  pounds.  Her  bowels  are  regular 
and  she  sleeps  well. 

Physical  examination  showed  good  nutrition,  marked  pallor,  nor- 
mal pupils,  glands,  and  reflexes.  Chest  was  negative,  save  for  a 
systolic  murmur,  heard  best  at  the  apex  of  the  heart,  but  audible 
also  over  the  whole  precordia.  Abdomen  and  extremities  negative. 
Blood  normal.  Slight  fever,  ranging  between  99°  and  100°  F.  for  the 
first  three  weeks  of  her  stay  in  the  hospital,  after  that  usually  below 
99°  F.  There  was  no  elevation  of  pulse  or  respiration.  Menstruation 
ceased  on  the  third  day  after  her  entrance  to  the  hospital,  but  began 
again  two  weeks  later  and  lasted  four  days.  The  blood  examination 
showed   the   following:    Red   cells,   1,500,000,  at  which  point   they 


582  DIFFERENTIAL  DIAGNOSIS 

remained  with  very  little  change  during  the  five  weeks  of  her  stay 
in  the  hospital;  hemoglobin,  50  per  cent.,  gradually  rising  to  60  per 
cent.;  white  corpuscles,  7500,  later  rising  to  10,000;  polynuclear 
leukocytes,  72  per  cent,  at  entrance,  80  per  cent,  five  weeks  later. 
The  stained  smear,  showed  great  variations  in  size  and  shape;  no 
achromia.  No  stippHng,  marked  abnormal  staining.  At  the  first  ex- 
amination no  nucleated  forms  were  seen;  three  weeks  later,  4  normo- 
blasts were  found.  Blood-plates,  280,000  at  entrance;  490,000  five 
weeks  later.  The  feces  were  negative  to  guaiac  on  three  successive 
examinations.  Pelvic  examination  showed  no  disease.  The  Wasser- 
mann  examination  was  positive. 

Discussion. — The  chief  impression  made  by  the  history  is  that 
we  are  dealing  with  a  secondary  anemia  due  to  excessive  uterine 
hemorrhage;  yet  it  is  almost  unprecedented  to  meet  with  anemia 
of  this  degree  in  a  patient  who  has  had  no  very  recent  or  colossal 
bleeding  and  who  has  been  able  to  work  until  five  days  before  her 
entrance. 

Posthemorrhagic  anemia  disables  a  patient  far  more  quickly 
and  completely  than  the  slowly  developing  primary  or  secondary 
type.  In  these  the  patient's  system  becomes  accustomed  to  the 
bloodlessness.  Some  sort  of  compensation  presumably  takes  place, 
and  the  patient  gets  along  surprisingly  well  with  half  or  a  quarter, 
or  even  a  fifth,  of  his  normal  quantity  of  red  cells. 

Since  neither  the  history  nor  the  general  physical  examination 
reveals  any  obvious  cause  for  the  anemia,  we  must  scrutinize  the  blood- 
picture  closely.  Everything  in  it  points  toward  pernicious  anemia, 
and  the  presence  of  a  positive  Wassermann  reaction  should  not,  as  it 
seems  to  me,  weigh  at  all  against  this  diagnosis.  A  person  with 
syphilis  is  not  thereby  immune  against  the  possibility  of  developing 
pernicious  anemia,  and  surely  patients  with  the  latter  disease  may 
acquire  syphilis.  Grave  anemias  do  occur  as  the  result  of  syphilis, 
but  not  without  more  obvious  lesions  than  have  occurred  in  this  case. 

Outcome. — At  the  end  of  five  weeks  the  patient  showed  con- 
siderable improvement  in  her  blood  and  some  in  her  general  condition. 
She  thought  she  would  be  as  comfortable  at  home  as  in  the  hospital, 
and  was  accordingly  discharged  March  8th.  The  treatment  through- 
out was  Fowler's  solution  with  tonics  and  laxatives. 

Case  258 

A  painter  of  forty,  born  in  Russia,  entered  the  hospital  November 
23,  1910.     For  the  past  three  months  the  patient  has  noticed  pallor 


PALLOR 


583 


and  pain  in  the  left  flank,  worse  when  he  urinates.  The  twenty-four- 
hour  amount  is  from  2  to  3  pints,  reddish-brown  in  color,  and  con- 
tains a  white  sediment.  Appetite,  bowels,  and  sleep  are  normal.  The 
patient  has  lost  no  weight  and  worked  until  entrance.  His  family 
history  and  past  history  are  otherwise  negative;  habits  excellent. 

Physical  examination  showed  fair  nutrition,  marked  pallor.  On 
the  lower  forearms,  above  the  inner  condyles,  were  two  moderately 
tender,  firm  masses  as  large  as  walnuts.  Pupils  and  reflexes  were 
normal.  The  heart  was  negative  save  for  a  soft  systolic  murmur, 
replacing  the  first  sound  at  the  apex  and  audible  all  over  the  pre- 
cordia.     The  aortic  second  sound  was  accentuated.      The  brachial 


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Fig.  218. — Chart  of  Case  258. 


arteries  pulsated  visibly.     The  lungs  showed,  at  the  right  apex  behind, 
a  few  crackling  rales  and  all  the  signs  of  slight  solidification. 

The  patient  entered  the  hospital  with  a  diagnosis  of  "nephritis,"  but 
examination  of  the  urine  showed  an  average  of  40  ounces  in  twenty- 
four  hours,  specific  gravity  1015,  no  albumin,  and  no  casts.  On  the 
25th  of  November  a  sterile  specimen  showed  a  sediment  consisting 
of  pus  in  small  clumps.  This  state  of  things  continued  thereafter, 
and  the  amount  of  sediment  varied  from  2  to  5  per  cent,  of  pure  pus. 
This  was  repeatedly  stained  for  tubercle  bacilli,  with  negative  results. 
Four  similar  examinations  of  the  sputum  were  also  negative.  The 
blood  showed  3,600,000  red  cells,  and  this  anemia  stayed  without 


584  DIFFERENTIAL   DIAGNOSIS 

much  change  during  the  four  weeks  of  his  stay  in  the  medical  wards. 
The  white  cells  varied  from  9000  to  13,000;  hemoglobin,  60  to  70  per 
cent.  The  stained  smear  showed  moderate  polynuclear  leukocytosis 
and  slight  achromia.  The  course  of  the  temperature  is  seen  in  Fig. 
218.     Blood-pressure,  115  mm.  Hg.,  systolic. 

Cystoscopy,  December  4th,  showed  a  normal  bladder,  but,  about 
the  left  ureteral  orifice,  marked  ulceration.  Practically  no  urine 
came  from  this  ureter,  but  only  thin  pus.  From  the  right  ureter  normal 
urine  was  obtained.  Dr.  Hugh  Cabot  stated  that  in  his  opinion  the 
left  kidney  was  largely  destroyed,  probably  by  tuberculosis.  The 
right  kidney  competent. 

November  28th  20  minims  of  the  urinary  sediment  were  in- 
jected into  a  guinea-pig.  January  14th  the  pig  was  killed.  Autopsy 
showed  tuberculous  lesions  of  the  glands,  spleen,  and  liver.  Cul- 
tures from  the  urine  always  showed  streptococci,  but  nothing  else. 
Two  negative  ic-rays  were  taken.  The  skin  tuberculin  test  was 
negative. 

Discussion. — The  history  points  toward  some  disease  in  or  near 
the  kidney.  The  physical  examination,  with  its  evidence  of  pyuria, 
fever,  and  anemia,  supports  this  conjecture  and  the  cystoscopy  con- 
firms it.  The  only  remaining  question  is  as  to  the  etiology  of  the 
renal  suppuration.  The  signs  at  the  apex  of  the  right  lung  naturally 
lead  us  to  assume  tuberculosis,  both  there  and  in  the  kidney.  The 
negative  examination  of  the  urinary  sediment  and  of  the  sputa  for 
tubercle  bacilli  incline  us  against  tuberculosis,  but  do  not  rule  it  out. 
Our  only  decisive  test  in  a  case  of  this  sort  is  animal  inoculation. 
The  anemia,  of  course,  is  secondary  to  renal  infection,  whatever  its 
bacteriologic  cause. 

Outcome. — On  the  20th  of  December  incision  was  made  over  the 
left  kidney,  which  was  found  everywhere  adherent,  as  if  plastered 
into  its  bed,  and  surrounded  by  a  markedly  thickened  inflammatory 
capsule.  At  the  lower  pole  an  abscess  outside  the  kidney  was  broken 
into  and  about  4  ounces  of  very  foul-smelling  pus  evacuated.  *The 
kidney  was  removed;  the  ureter  found  greatly  thickened,  as  large 
as  the  forefinger.  It  was  removed,  together  with  the  kidney,  micro- 
scopic examination  of  which  showed  that  its  substance  was  largely 
replaced  by  fibrous  tissue,  its  pelvis  and  calyces  dilated  and  full  of 
pus.  The  patient  did  not  rally  well  after  the  operation,  and  died  on 
the  2 2d  of  December.  Autopsy  showed  an  evacuated  subdiaphrag- 
matic abscess  in  the  retroperitoneal  tissues  about  the  kidney,  with 
gangrene  of  these  tissues  extending  up  to  the  diaphragm,  posteriorly; 


PALLOR  585 

abscess  of  the  spleen,  thrombosis  of  the  left  external  iliac  and  femoral 
veins;  obsolete  tuberculosis  at  the  apices  of  both  lungs  and  in  the 
bronchial  lymphatic  glands. 

Case  259 

A  housekeeper  of  forty -four  entered  the  hospital  February  23,  191 1. 
The  patient's  father  died  of  cancer  of  the  stomach  at  fifty-five;  mother, 
of  some  chronic  stomach  and  intestinal  trouble  at  fifty-seven.  One 
brother  has  nervous  dyspepsia,  one  sister  has  the  same  trouble,  and 
another  sister  has  had  stomach  trouble  for  four  years,  but  has  recently 
recovered. 

The  patient's  general  health  has  always  been  poor.  For  years, 
she  says,  she  has  been  as  pale  as  she  now  is.  At  twenty-nine  she  had  a 
nervous  breakdown,  with  general  tremor,  weakness,  and  inabiHty  to 
use  her  eyes..  She  did  nothing  for  six  years,  during  which  time 
she  was  several  times  in  hospitals  for  operations  on  eye  muscles, 
for  curettage,  and  other  troubles.  Twelve  years  ago  the  right  ovary 
was  removed.  Most  of  the  time  since  she  has  been  working  as  a 
governess  and  housekeeper,  with  only  one  breakdown,  although 
she  has  had  constant  trouble  with  sour  stomach,  gaseous  eructations, 
epigastric  tenderness,  and  constipation.  Her  menstruation  began  at 
fourteen  and  was  regular  until  June,  19 10,  since  when  she  has  had  but 
one  period,  six  weeks  ago. 

A  year  ago  she  began  to  be  troubled  by  sore  tongue,  and  at  in- 
tervals it  has  been  sore  ever  since.  In  September,  1910,  she  began  to 
have  what  she  calls  "bihous  attacks,"  i.^e.,  nausea  and  vomiting  at 
irregular  intervals,  without  relation  to  meals,  associated  with  anorexia 
and  constipation,  but  without  pain  or  jaundice.  For  the  past  week  she 
has  vomited  once  or  twice  a  day.  Since  January,  191 1,  she  has  noticed 
dyspnea  on  exertion,  associated  with  some  pain  in  the  chest.  She 
sleeps  well  with  one  pillow  and  has  lost  no  weight.  She  knows  of  no 
fever. 

Physical  examination  showed  marked  sallow  pallor.  Pupils, 
glands,  and  reflexes  normal.  Mouth  and  throat  negative.  Heart 
sounds  somewhat  irregular,  distant,  and  of  poor  quality.  Soft,  blow- 
ing, systolic  murmur,  audible  all  over  the  precordia  and  in  the  left 
axilla,  loudest  at  the  apex.  No  evidence  of  cardiac  enlargement,  no 
accentuation  of  any  sound.  Lungs  and  abdomen  negative,  except 
that  the  liver  dulness  extended  3  cm.  below  the  ribs,  where  the  edge 
of  the  organ  was  doubtfully  felt.  There  was  intermittent  coarse 
tremor  of  both  hands,  especially  the  right.     The  urine  averaged  45 


;86 


DIFFERENTIAL  DIAGNOSIS 


ounces  in  twenty-four  hours;  specific  gravity,  1004  to  loio;  albumin 
sometimes  absent,  sometimes  present,  slightest  possible  trace.  Sedi- 
ment negative.  Five  examinations  of  the  stools  were  negative. 
Examination  of  the  fundi  showed  patches  of  exudate  and  small  hem- 
orrhages in  the  left  retina. 

The  condition  of  the  blood  is  shown  in  Fig.  219.     The  red  cells 
were  mostly  of  the  large  type  and  well  stained,  though  a  few  of  them 


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Fig.  219. — Chart  showing  course  of  red  cells,  white  cells,  and  hemoglobin  in  Case  259. 


were  very  achromic.  Occasionally  very  large  purplish  or  stippled 
cells  were  seen.  Blood-plates  seemed  to  be  very  much  diminished 
and  there  was  much  deformity  in  the  shape  of  the  red  cells.  At 
entrance  no  nucleated  forms  were  seen.  On  March  7th  a  few  normo- 
blasts appeared;  on  the  14th,  2  megaloblasts  were  seen  while  counting 
200  white  cells;  on  the  2 2d,  2  normoblasts  and  2  megaloblasts;  on 
March  28th,  2  megaloblasts  only.    On  the  3d  and  8th  of  April  normo- 


PALLOR  587 

blasts  became  very  abundant,  30,  and  18  megaloblasts.  After  that 
the  nucleated  cells  became  rare  and  at  times  could  not  be  found 
at  all.  The  leukocytes  at  entrance  numbered  5000,  sagged  in  two 
weeks  to  2500,  then  gradually  rose  with  the  increasing  red  cells  to 
15,000;  the  polynuclear  varieties  meantime  rising  from  6c  to  83  per 
cent.     Throughout  the  whole  course  the  blood-plates  were  diminished. 

April  5th  0.6  gm.  of  salvarsan  was  injected  deep  in  the  left 
gluteal  region,  and  the  improvement  in  the  patient's  blood  dated 
from  this  time.  Up  to  the  27th  of  April  she  seemed  to  be  decidedly 
improving,  though  there  was  at  times  a  little  edema  of  the  face.  On 
the  5  th  of  May  she  complained  of  headache  and  had  slight  coryza. 
This  steadily  increased,  and  at  midnight  on  the  6th  she  became  un- 
conscious. Soon  after  she  had  a  generalized  clonic  convulsion  and 
bit  her  tongue.  The  radial  pulse  showed  alternation.  The  face 
seemed  more  edematous  than  before.  There  were  many  crackling 
rales  at  the  base  of  the  right  lung;  otherwise  physical  examination 
was  negative.  On  the  9th  Dr.  Brewster  removed  the  area  of  fat  and 
muscle  about  the  site  where  "606"  had  been  injected.  The  specimen 
examined  microscopically  showed  necrosis  of  fat  and  muscle  and  a 
small  amount  of  arsenic  was  detected  on  chemical  examination. 

Throughout  the  three  months  of  her  stay  in  the  hospital  she 
maintained  her  weight,  but  had  most  of  the  time  a  sHght  tempera- 
ture in  the  evening,  the  highest  point  reached  varying  between  99.5° 
and  100.5°  F. 

Discussion. — This  patient  seems  to  be  predisposed  by  inheritance 
to  stomach  trouble  and  possibly  to  cancer.  She  has  also  suffered 
many  things  from  many  physicians,  as  nervous  sufferers  are  un- 
fortunately so  apt  to  do.  The  operations  upon  her  eyes  and  her 
pelvic  organs  are  of  the  type  so  often  done,  especially  in  the  last 
decade,  because  of  the  utterly  false  surgical  dogma  that  all  nervous 
symptoms  must  have  "a  cause,"  by  which  they  mean  a  cause  open 
to  surgical  treatment. 

The  history  of  sore  tongue  accompanying  a  marked  anemia 
makes  it  incumbent  upon  us  to  look  with  special  care  for  evidence 
of  pernicious  anemia,  since  many  cases  of  that  disease  begin  each  one 
of  the  successive  waves  of  illness  with  a  sore  mouth.  Such  a  suspi- 
cion is  here  strengthened  by  the  finding  of  retinal  hemorrhages, 
hepatic  enlargement,  and  a  high  color  index.  Further  study  of  the 
blood  leaves  no  considerable  doubt  of  the  diagnosis. 

A  few  words  may  here  be  said  regarding  the  salvarsan  treatment 
for  pernicious  anemia.    Certainly  a  single  dose  is  often  devoid  of  any 


588  DIFFERENTIAL  DIAGNOSIS 

good  effect  whatever.  On  the  other  hand,  the  recent  cases  reported 
from  Dr.  Mumford's  clinic  at  Clifton  Springs  by  Dr.  Brotherhood 
arouse  the  hope  that  by  giving  small  and  repeated  doses  of  salvar- 
san  we  may  produce  at  any  rate  a  longer  and  prompter  remission 
of  the  symptonis  than  can  be  expected  from  the  activities  of  nature 
unaided,  or  from  the  ordinary  methods  of  treatment.  That  salvarsan 
can  cure  the  disease  I  do  not  for  a  moment  beheve.  It  is  a  palliative, 
not  an  etiologic,  treatment,  for,  although  there  are  certain  scraps  of 
evidence  pointing  toward  an  infectious  etiology  for  pernicious  anemia,^ 
these  hmts  are  by  no  means  conclusive.  What  other  infectious  dis- 
ease begins  so  regularly  at  the  arteriosclerotic  age? 

Outcome. — On  the  15th  of  May  the  clinical  note  is  "still  doing 
well,"  but  on  the  i8th  she  died,  rather  suddenly.  Autopsy  No.  2854, 
May  19th,  showed  arteriosclerotic  nephritis  with  foci  of  suppura- 
tion; hyperplasia  of  the  bone-marrow;  slight  hypertrophy  of  the 
heart;  streptococcic  septicemia;  chronic  pleuritis;  general  anemia. 

Remarks. — The  fact  that  the  kidneys  were  markedly  diseased 
would  lead  some  incautious  observers  to  beHeve  that  this  case  sup- 
ports the  theory  often  advanced  on  similar  equivocal  evidence  that 
nephritis  can  cause  pernicious  anemia.  When  two  diseases  occur  so 
frequently  without  any  known  connection  with  one  another,  one 
needs  a  good  deal  more  than  the  fact  of  their  simultaneous  occur- 
rence within  a  single  body  to  constitute  evidence  of  an  etiologic  con- 
nection. Whether  arsenic-poisoning  played  any  part  in  this  patient's 
demise  I  cannot  definitely  state.  I  see  no  good  reason  to  believe  so, 
though  it  is  possible  that  the  end  may  have  been  hurried  by  the  un- 
fortunate accident  resulting  from  the  way  in  which  salvarsan  was 
at  that  period  not  infrequently  given. 

Case  260 

A  schoolgirl  of  eight  years  entered  the  hospital  March  13,  191 1. 
The  little  girl's  mother  has  had  ten  other  children  and  four  mis- 
carriages. Eight  children  are  living  and  well.  The  patient  herself 
has  had  measles  and  whooping-cough,  and  when  four  years  old  was 
treated  in  the  Neurologic  Department  and  at  the  City  Hospital  for 
multiple  joint  pains,  with  tenderness,  but  no  swelling.  A  diagnosis  of 
multiple  neuritis  was  made.  She  was  in  bed  three  weeks  and  could 
not  walk  for  five  weeks  from  the  onset. 

After  that  she  was  in  vigorous  health   until  December  10,  1910, 

^  Herbert  C.  MofiStt,  Transactions  of  the  Association  of  American  Physicians,  1911, 
p.  288. 


PALLOR  589 

when  she  had  a  sore  throat  and  an  attack  of  pain  in  many  joints, 
though  without  swelHng.  She  was  in  bed  a  week,  but  has  never  been 
really  well  since.  For  an  hour  on  the  15th  of  December  she  was  said 
to  have  been  temporarily  blind,  and  for  several  months  past  she  had 
now  been  troubled  with  frontal  headache.  Nevertheless,  until  four 
days  ago  the  parents  considered  her  fairly  well. 

Four  days  ago  her  mother  noticed  pallor  and  pufhness  of  the  face. 
The  child  had  a  good  appetite,  but  vomited  most  of  her  food  soon 
after  eating. 

Physical  examination  showed  marked  pallor  and  edema  of  the 
face  and  extremities.  Pupils,  glands,  and  reflexes  negative.  The 
chest  showed  a  slight  rachitic  rosary.  The  cardiac  dulness  reached 
2  cm.  to  the  right  of  midsternum  and  7  cm.  to  the  left  of  the  nipple 
line.  There  were  no  murmurs  or  accentuations.  In  the  lungs  abun- 
dant bubbling  rales  were  heard  throughout  both  chests.  There  was 
soft  edema  of  the  extremities;  otherwise  physical  examination  was 
negative.  Blood-pressure,  125  to  135  mm.  Hg.,  systolic.  Stained 
smear  showed  moderate  achromia;  hemoglobin,  80  per  cent.;  white 
cells,  14,000  to  16,000.  The  urine  averaged  35  ounces  in  twenty-four 
hours,  with  a  slight  trace  of  albumin;  specific  gravity  usually  in  the 
vicinity  of  loio,  occasionally  rising  to  1020.  Granular,  cellular,  and 
bloody  casts,  with  some  pus,  were  present  throughout  most  of  her 
stay,  though  after  the  ist  of  April  the  amount  of  blood  rapidly  di- 
minished and  soon  disappeared.  There  was  no  fever  during  the  five 
weeks  of  her  stay  in  the  hospital  Under  daily  hot  tub  baths  of  fifteen 
minutes,  at  temperature  of  100°  F.,  gradually  raised  to  112°  F.,  fol- 
lowed by  wrapping  in  warm  blankets,  the  child  steadily  improved. 
She  was  given  a  diet  from  which  meat  was  omitted  and  salt  limited. 
The  bowels  were  moved  by  2  drams  of  sodium  sulphate  every  morn- 
ing. The  edema  was  gone  by  the  ist  of  April  and  the  baths  were 
then  omitted. 

Discussion. — Can  this  patient  have  had  a  multiple  neuritis  at 
the  age  of  four?  I  never  heard  of  any  such  diagnosis  or  read  of  any 
such  cause.  Does  it  not  seem  more  probable  that  she  had  a  rheu- 
matic infection,  similar  to  that  which  occurred  in  19 10?  I  am  in- 
clined to  believe  so.  Blindness  and  frontal  headache,  following  im- 
mediately upon  an  attack  of  tonsillitis  and  arthritis,  make  us  con- 
fident that  the  urine  will  show  clear  evidence  of  nephritis,  especially 
when  pallor  and  pufi&ness  of  the  face  ensue.  A  systolic  blood-pressure 
of  135  mm.  Hg.  constitute  hypertension  in  a  girl  of  eight  years  and 
further  supports  the  diagnosis  of  nephritis. 


5  go  DIFFERENTIAL  DIAGNOSIS 

The  case  is  of  interest  as  an  example  of  posttonsillar  or  strepto- 
coccic nephritis.  In  my  opinion,  there  is  no  other  cause  for  acute 
nephritis  so  common  as  this.  It  is  impossible  to  say  that  many  cases 
of  the  so-called  scarlatinahiephritis  are  not,  in  fact,  streptococcic  in 
origin.  Those .  following  tonsillitis  are  not  so  often  discovered,  be- 
cause we  have  not  yet  become  accustomed  to  expect  nephritis  as  a 
complication  of  that  disease. 

Outcome. — By  the  9th  she  seemed  nearly  well,  and  on  the  15th 
was  discharged.  In  April,  19 13,  she  reported  herself  entirely  well. 
The  urine  was  not  obtained. 

Case  261 

A  farmer  of  sixty-two  entered  the  hospital  March  24,  191 1.  The 
patient  has  had  stomach  trouble  for  the  past  fifteen  years,  but  it  has 
never  prevented  his  working.  He  has  epigastric  pain  beneath  the 
left  costal  margin  occurring  with  great  definiteness,  two  and  a  half 
hours  after  meals,  especially  after  breakfast  and  lunch.  He  says  the 
pain  is  Hke  hungry  kittens.  It  is  immediately  relieved  by  food,  and 
for  years  he  has  carried  crackers  or  doughnuts  in  his  pocket  to  take 
when  the  pain  comes.  He  also  gets  rehef  from  pressure,  and  often 
throws  himself  across  a  bag  of  wool  or  bale  of  hay  for  comfort. 

This  condition  has  shown  no  marked  change  until  five  weeks  ago. 
There  have  often  been  remissions,  lasting  several  weeks  or  months. 
Five  weeks  ago  he  noticed  that  he  was  getting  pale,  and  shortly  after 
had  an  attack  of  diarrhea  and  vomiting,  lasting  three  days.  Since 
then  he  has  felt  weak,  though  he  has  been  up  and  about  the  house. 
Two  weeks  ago  he  rose  from  a  chair  to  get  a  drink  of  water  and  feU, 
without  losing  consciousness.  There  was  no  vertigo,  and  he  got  up 
without  assistance.  A  week  ago  he  had  a  similar  experience.  He 
thinks  he  may  have  lost  weight.  He  is  quite  sure  he  has  lost  strength, 
though  he  feels  able  and  willing  to  work  to-day.  His  family  history 
and  habits  are  good.  He  denies  venereal  disease.  His  bowels  moved 
daily  until  within  a  few  weeks.  He  has  always  led  the  vigorous, 
out-of-door  life  of  a  fanner. 

Physical  examination  showed  marked  pallor,  good  nutrition; 
pupils  slightly  irregular,  otherwise  normal.  Glands  and  reflexes 
negative.  Chest  and  abdomen  negative.  The  course  of  the  tem- 
perature is  shown  in  Fig.  220.  Urine  was  negative.  The  patient 
weighed  142  pounds,  without  clothes.  The  stools,  examined  six 
times,  showed  a  marked  reaction  to  guaiac,  but  no  other  abnormaHty. 
The  blood  showed  red  cells,  1,800,000;  white  cells,  14,000;  hemoglobin, 


PALLOR 


591 


35  per  cent.  There  was  no  marked  change  from  these  figures  in  four 
examinations,  at  weekly  intervals.  The  stained  specimen  showed 
almost  no  achromia,  slight  deformities,  the  red  cells  often  oversized, 
and  many  of  them  off-color,  even  blue.  There  was  a  marked  poly- 
nuclear  leukocytosis.  Altogether,  an  equivocal  blood,  but,  when  taken 
in  connection  with  the  history,  probably  due  to  secondary  anemia. 
In  the  fasting  stomach  70  c.c.  of  turbid,  coffee-colored  fluid  was 
found,  reacting  strongly  to  guaiac.  No  further  examination  was 
made. 

The  first  four  days  after  his  entrance  to  the  hospital  he  had  a 
persistent  hiccup,  which  was  checked,  however,  by  a  small  dose  of 


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morphin  and  did  not  recur.  Most  of  the  time  the  patient  lay  in  a 
semicomatose  condition,  occasionally  irrational,  but  able  to  answer 
questions.  An  attempt  was  made  to  secure  a  donor  of  blood  for 
transfusion,  but  unsuccessfully.  April  nth  and  13th  he  complained 
in  the  night  of  pain  in  the  chest,  but  during  most  of  the  time  lay  as  if 
asleep.     The  fundus  oculi  was  normal. 

Discussion. — The  only  organic  disease  of  the  stomach  that  lasts 
fifteen  years  is  peptic  ulcer  and  its  results.  If  this  patient  has  had  but 
one  trouble  throughout  the  whole  of  his  illness,  it  is  inevitable  for  us 
to  call  it  ulcer.     His  recent  pallor  and  weakness  are  then  explainable 


592  DIFFERENTIAL  DIAGNOSIS 

as  the  result  of  hemorrhage,  which  may  have  passed  out  through  the 
bowel  without  his  knowing  anything  about  it.  Some  features  of  the 
blood  examination  parallel  those  of  pernicious  anemia,  but  the  well- 
marked  polynuclcar  leukocytosis,  taken  in  connection  with  the  typical 
gastric  history,  should  leave  us  no  doubt  that  the  anemia  is,  in  reality, 
of  the  secondary  type. 

The  latter  symptoms  in  this  case  present  an  excellent  type  of  those 
which  are  usually  explained  by  saying  that  a  peptic  ulcer  has  become 
cancerous.  Like  many  better  men,  I  was  misled  into  making  such  a 
diagnosis  in  this  case. 

Outcome. — On  the  15th  of  April  he  died.  Autopsy  showed  a  per- 
forated ulcer  of  the  stomach  with  localized  peritonitis.  Cancer  had 
been  considered  the  most  likely  diagnosis  before  death. 

Case  262 

A  housekeeper  of  thirty-six  entered  the  hospital  January  i,  191 2. 
The  patient's  father  died  of  Bright's  disease;  in  other  respects  her 
family  history  is  excellent.  She  has  never  been  sick  before,  but  for 
the  past  three  months  has  had  a  great  deal  of  flowing  at  irregular  in- 
tervals. Three  years  ago,  when  walking  home  one  cold  evening,  she 
left  her  coat  unbuttoned  and  thinks  she  caught  cold.  For  two  weeks 
after  this  she  had  very  frequent  and  painful  micturition,  which, 
however,  got  well  without  any  further  complications.  Soon  after 
this,  without  any  known  cause,  she  rapidly  lost  strength  and  became 
very  pale.  A  vacation  in  Baltimore  benefited  her  a  good  deal,  and 
she  went  back  to  work  on  her  return.  She  has  worked  for  a  greater 
part  of  the  time  since  then  up  to  last  Thanksgiving,  six  weeks  ago, 
though  she  has  remained  pale  all  this  time  and  has  never  felt  very 
strong.  Since  Thanksgiving  she  has  been  in  bed,  though  she  com- 
plains of  nothing  whatever  except  weakness.  It  is  hard  work  for  her 
now  even  to  think.  She  absolutely  denies  any  shortness  of  breath, 
any  edema,  vomiting,  headache,  or  diarrhea.  She  has  an  occasional 
slight  hacking  cough,  without  sputum.  She  has  had  no  fever,  chills, 
or  sweats,  no  fainting  or  vertigo,  and  no  pain  in  any  part  of  the  body. 
Her  weight,  she  believes,  has  remained  about  the  same. 

Physical  examination  shows  fair  nutrition  and  considerable  pallor. 
No  jaundice.  The  pupils  are  small,  slightly  irregular  in  shape,  react 
normally  to  light  and  well  to  distance.  Knee-jerks  are  present  and 
equal.  All  the  other  reflexes  are  normal.  There  are  many  small, 
firm,  non-tender,  discrete  glands  in  the  neck,  axillae,  and  groins.  The 
tongue  shows  a  thick,  brown  coat.     The  mouth  and  throat  are  nega- 


PALLOR  593 

tive.  The  heart's  apex  is  seen  and  felt  in  the  fifth  interspace,  7  cm. 
outside  the  nipple.  Its  dulness  extends  4  cm.  beyond  the  midsternal 
line.  At  the  apex  is  a  harsh,  long,  systolic  murmur,  transmitted  to 
the  axilla.  The  pulmonic  second  sound  is  moderately  accentuated. 
The  lungs  are  negative.  The  liver  dulness  extends  7^  cm.  below  the 
ribs  and  as  high  as  the  fifth  interspace  in  the  nipple  line.  A  rounded, 
slightly  tender  edge  is  felt.  The  spleen  is  enlarged  by  percussion  and 
its  edge  is  felt  just  above  the  level  of  the  navel.  It  is  not  tender. 
The  extremities  are  negative.  Systolic  blood-pressure,  140.  The 
urine  20  to  40  ounces  in  twenty-four  hours,  1012  to  1019  in  specific 
gravity,  slight  trace  of  albumin,  rare  granular  and  hyahne  casts  with 
cells  adherent.  The  blood  shows  red  cells  2,600,000;  white,  21,000  to 
23,000;  hemoglobin,  65  per  cent.;  polynuclear  cells,  75  per  cent. 
Stained  smear  shows  sHght  variations  in  size  and  shape,  but  no 
achromia  or  abnormal  staining;  i  normoblast.  The  Wassermann 
reaction  is  negative. 

The  patient's  family  physician  later  told  us  that  on  examination 
three  weeks  ago  he  found  a  large  dilated  heart  with  a  mitral  murmur 
and  a  weak,  rapid  pulse.  Under  digitaHs  and  rest  she  improved  very 
much.  After  her  return  from  Baltimore,  although  she  worked  as  a 
milliner,  she  was  treated  twice  for  attacks  of  broken  compensation. 
Her  physician  also  states  that  since  Thanksgiving  she  has  had  several 
chills  followed  by  fever,  and  has  complained  of  pain  along  the  lines 
of  the  ureters. 

On  the  2d  of  January  a  diastolic  murmur  was  heard  in  the  second 
right  interspace  and  along  the  right  sternal  margin.  Corrigan  pulse, 
capillary  pulse,  and  other  vascular  phenomena  therewith  associated 
were  detected  at  the  same  time.  The  same  afternoon  she  had  a  chill, 
followed  by  a  sharp  rise  in  temperature;  the  next  day  another  chiU, 
with  slight  spasm  and  moderate  tenderness  in  the  region  of  the  spleen; 
also  crops  of  petechiae  on  each  arm.  Blood-culture  gave  a  Gram- 
positive  diplococcus,  interpreted  as  a  contamination.  The  patient's 
condition  was  very  poor.  On  the  4th  crops  of  petechise  spread  over 
the  entire  body.  The  heart  became  very  rapid,  and  there  were 
several  attacks  of  marked  cyanosis  and  pectoral  oppression,  lasting 
ten  to  twenty  minutes. 

Discussion. — So  much  weakness,  unexplained  and  associated  with 
extreme  pallor,  cannot  but  alarm  us  with  its  likeness  to  the  onset  of 
many  a  case  of  pernicious  anemia,  but  the  condition  of  the  blood 
reassures  us. 

The  heart  lesions  lead  us  to  look  in  that  direction  for  an  explana- 

VoL.  11—38 


594  DIFFERENTIAL   DIAGNOSIS 

tion  of  the  patient's  anemia  and  other  symptoms.  Here  we  have  a 
"causeless"  cardiac  weakness,  with  marked  enlargement  and  normal 
blood-pressure.  We  have  also  an  enlargement  of  the  spleen  and 
liver.  Cardiac  disease  does  not  enlarge  the  spleen,  hence  we  must 
look  elsewhere .  for  an  explanation.  The  general  glandular  enlarge- 
ment prepares  our  mind  for  the  appearance,  late  in  the  case,  of  a 
diastolic  murmur  which  points  very  directly  to  syphilis,  and  gives  us 
a  diagnosis  which  can  explain  the  "causeless"  cardiac  weakness  and  the 
splenic  tumor,  as  well  as  the  anemia. 

On  the  other  hand,  the  crops  of  purpuric  spots  which  marked 
the  latter  days  of  the  patient's  life  are  such  as  one  most  often  sees  in 
connection  with  the  rheumatic  or  streptococcic  type  of  heart  disease. 
Except  for  this,  however,  everything  points  in  the  other  direction, 
that  is,  everything  except  the  negative  Wassermann,  which  cannot 
be  ignored,  but  which  need  not  upset  the  diagnosis  otherwise  well 
supported. 

Outcome. — On  the  5th  of  January  the  patient  died.  Autopsy 
showed  syphilitic  aortitis;  aneurysm  of  the  celiac  axis;  fibrous  de- 
generation of  the  aortic  valve  and  a  slight  degree  of  the  same  condi- 
tion of  the  mitral  valve;  hypertrophy  and  dilatation  of  the  heart; 
acute  glomerulonephritis;  slight  chronic  perihepatitis  and  perispleni- 
tis; chronic  salpingitis;  chronic  tuberculous  pleuritis.  No  evidence 
of  emboli. 

Remarks. — I  was  wholly  unprepared  to  find  the  acute  glomerulo- 
nephritis shown  at  autopsy.  Possibly  it  may  have  been  due  to  a 
terminal  infection  which  no  one  could  predict.  Certainly  the  urinary 
examination  made  at  the  time  of  the  patient's  entrance  would  not 
warrant  any  such  diagnosis,  though  the  conditions  found  were  not 
those  of  health. 

The  frequency  of  chronic  perihepatitis  and  perisplenitis  at  autopsy 
in  cases  of  syphilis  tempts  one  to  regard  such  lesions  as  of  syphilitic 
origin,  even  in  cases  where  the  latter  disease  is  by  no  means  clearly 
shown. 

Case  263 

The  patient  was  a  Finlander,  thirty  years  old,  and  has  worked  in  a 
stone  quarry.  He  entered  the  hospital  June  19,  191 2,  complaining 
that  for  a  month  he  has  been  getting  yellow.  He  has  worked  until 
nine  days  ago,  though  for  two  months  he  has  noticed  that  his  legs  are 
somewhat  weak.  His  family  history,  past  history,  and  habits  are 
excellent.     Since  he  stopped  work  he  has  noticed  vertigo,  headache, 


PALLOR  595 

and  tmnitus,  with  slight  shortness  of  breath.  As  he  hes  in  bed  he 
feels  perfectly  well,  has  a  good  appetite,  and  no  pain.  He  has  lost  a 
few  pounds  in  weight,  but  thinks  he  is  now  regaining  them. 

Physical  examination  shows  good  nutrition  and  marked  yellowish 
pallor,  normal  pupils,  glands,  and  reflexes.  The  chest  is  negative,  save 
for  a  few  moist  rales  heard  below  the  angle  of  the  left  scapula  and  at 
the  bottom  of  the  left  axilla,  not  associated  with  any  other  phys- 
ical signs  of  disease.  The  abdomen  and  extremities  are  negative. 
Urine  negative.  Systolic  blood-pressure,  115.  The  temperature 
occasionally  rose  to  99.5°  F.  in  the  afternoon  during  the  first  week  of 
his  stay;  after  that  normal  or  subnormal.  The  blood  showed  red 
cells  1,000,000;  white  cells,  6000;  hemoglobin,  40  per  cent.  The 
stained  smear  showed  no  achromia,  many  large,  deeply  staining  red 
cells.  Marked  variations  in  size  and  shape  and  many  abnormally 
stained  cells,  '  but  no  stippling.  Blood-plates  decreased.  Three 
normoblasts  and  4  megaloblasts  were  seen  while  counting  200  white 
cells. 

Discussion. — Pernicious  anemia  was  the  house  officer's  diagnosis 
in  this  case,  and  there  was  certainly  much  to  justify  it,  for  the  blood 
was  absolutely  typical  and  the  ordinary  physical  examination  showed 
no  cause  for  the  anemia.  But  the  patient's  youth  should  lead  one 
to  scrutinize  such  a  diagnosis  carefully  and  to  look  for  every  other 
possible  explanation.  Certainly  not  more  than  once  in  a  hundred 
times  does  true  pernicious  anemia  occur  in  a  man  of  this  age.  In  a 
young  woman  it  is  not  so  rare. 

Still  more  significant,  however,  is  the  patient's  nationality,  for 
we  know  that  of  all  places  in  the  world  Finland  is  the  one  most  notor- 
iously associated  with  fish  tapeworm  anemia,  whose  striking  resem- 
blance to  pernicious  anemia  was  first  made  clear  by  Schaumann's 
classical  monograph.^ 

This  is  one  of  the  very  few  cases  in  which  I  have  been  able  to 
believe  that  I  have  saved  a  patient's  life.  Had  not  the  eggs  of  fish 
tapeworm  been  looked  for  under  my  direction,  and  the  appropriate 
treatment  for  the  expulsion  of  the  worm  given,  this  patient  might 
have  been  allowed  to  die  with  the  diagnosis  of  pernicious  anemia. 

Outcome. — The  patient's  youth  and  his  race  at  once  suggested 
the  possibility  of  a  fish  tapeworm  as  the  cause  of  his  anemia.  Ex- 
amination of  the  stools  showed  the  eggs  of  that  tapeworm.  The 
patient  was  accordingly  given  a  milk  diet  for  twenty-four  hours  with 
very  free  purgation;   after  that  pelletierin  tannate,   i  gr.,  together 

^  Berlin,  1904,  Hirschwald. 


596  DIFFERENTIAL  DIAGNOSIS 

with  oleoresin  of  aspidium,  15  gr,  in  capsule,  one  every  two  min- 
utes for  eight  doses.  The  next  day  the  patient  passed  practically  the 
whole  of  a  full-grown  fish  tapeworm.  The  head  was  not  found. 
During  the  ten  days  following  the  expulsion  of  the  tapeworm  his 
hemoglobin  roSe  10  per  cent,  and  his  blood  improved  proportionately 
in  other  respects.  Thereafter  he  rapidly  improved,  and  went  home 
on  the  ist  of  July  to  finish  his  convalescence. 


CHAPTER  XV 

SWELLING  OF  THE  ARM 

The  symptom  is  rare,  if  we  except  the  cases  whose  diagnosis  is 
obvious.  Swelling  of  an  arm  as  the  result  of  septic  processes  in  the 
hand  or  higher  up  is,  of  course,  not  uncommon,  but  needs  no  discus- 
sion or  comment.  It  is  the  cases  without  any  such  obvious  explana- 
tion that  I  have  called  rare.  They  occur,  now  and  then,  in  the  course 
of  cardiac  disease,  apparently  because  the  dropsical  patient  has  lain 
persistently  upon  one  side  so  that  the  edematous  fluid  has  settled 
there  by  gravitation. 

Aside  from  this,  a  phlebitis  may  occur  in  the  course  of  heart 
disease  as  well  as  in  other  conditions,  but  in  the  arm  a  phlebitis  often 
presents  no  obvious  tender  cord,  such  as  we  can  palpate  on  the  inside 
of  a  leg  similarly  affected.  Hence,  the  diagnosis  of  phlebitis  in  the 
arm  has  often  to  be  made  wholly  by  exclusion  of  other  causes  for  the 
swelling  that  we  find.  One  settles  down  upon  that  diagnosis  in  cases 
when  they  find  no  evidence  of  cervical  or  mediastinal  pressure  {cervical 
rib,  glandular  swellings,  malignant  disease,  aneurysm). 

Among  the  mediastinal  tumors  which  cause  an  arm  to  swell,  lym- 
phoblastoma (Hodgkin's  disease)  is  by  far  the  most  common. 

Cancerous  metastases  in  the  axillary  glands  after  tumor  of  the  breast 

usually  leave  us  in  no  doubt  of  the  cause  of  the  resulting  edema  in  the 

arm.     On  the  other  hand,  axillary  abscess  may  obstruct  the  venous 

circulation  and  produce  a  swollen  arm  without  giving  us  any  clear 

evidence  of  its  presence,  for  such  an  abscess  often  arises  very  deep  in  the 

tissues.     The  presence  of  slight  unexplained  fever  and  leukocytosis  in 

connection  with  what  is  supposed  to  be  a  glandular  tumor  of  the  axilla 

gives  us  ground  for  suspecting  an  abscess  behind  it. 
«, 

Case  264 

A  housewife  of  thirty-eight  entered  the  hospital  July  15,  1906. 
For  the  past  three  years  she  has  had  dyspnea  and  palpitation  on  exer- 
tion, with  swelling  of  the  feet  at  times.  For  eight  months  she  has  been 
in  bed  a  good  deal  of  the  time  with  partial  orthopnea.  Nocturia,  2. 
She  has  had  headaches  all  her  hfe,  but  less  of  late.  Appetite  and 
bowels  normal. 

597 


598 


DIFFERENTIAL   DIAGNOSIS 


Four  days  ago  the  right  arm  swelled  and  the  edema  disappeared 
from  other  parts  of  the  body.  The  whole  arm  was  at  first  much 
enlarged  and  purple  in  color.     It  is  now  slightly  smaller. 

Physical  examination  shows  fair  nutrition,  nervous,  quick,  and 
tremulous  movements,  prominent  eyeballs,  no  goiter.  The  heart's 
impulse  extends  to  the  anterior  axillary  line,  in  the  fifth  and  sixth 
spaces.  Its  action  is  rapid  and  irregular.  The  sounds  are  faint  but 
clear.  The  aortic  second  is  accentuated.  No  murmur.  The  lungs 
show  coarse  crackles  at  the  bases,  otherwise  normal.  There  is  dulness 
in  the  flanks,  not  shifting  with  change  of  position.  Abdomen  other- 
wise negative.  The  right  knee-jerk  not  obtained,  the  other  normal. 
The  right  arm  is  greatly  swollen  throughout  and 
pits  on  pressure.  The  right  leg  is  also  very 
edematous,  and  there  is  considerable  edema  of 
the  right  side  of  the  trunk,  front  and  back. 
There  is  also  slight  edema  of  the  left  side  of  the 
body,  especially  the  left  leg.  The  white  cells 
number  33,200;  hemoglobin,  95  per  cent.  The 
temperature  is  as  seen  in  Fig.  221.  The  urine  is 
negative  save  for  a  slight  trace  of  albumin. 
Under  poulticing,  purgatives,  digitalis,  and  rest 
the  edema  rapidly  diminished.  The  day  after 
entrance  an  apex  systoHc  murmur  appeared,  and 
the  first  sound  was  noticed  to  be  sharp  and  short. 
Discussion. — A  history  of  three  years'  dysp- 
nea on  exertion  and  eight  months'  orthopnea 
makes  us  naturally  prone  to  believe  that  a 
swollen  right  arm  like  that  here  described  is 
connected  with  heart  disease.  The  heart  lesion 
from  which  this  patient  suffers  seems  to  me 
most  like  mitral  stenosis.  In  favor  of  this  we  have  the  marked  lateral 
enlargement  of  the  heart,  its  rapid,  irregular  action,  and  the  sharp, 
short  first  sound  at  the  apex.  Even  without  a  rheumatic  history,  a 
presystolic  murmur,  or  an  accentuated  pulmonic  second  sound,  such 
physical  signs  make  mitral  stenosis  the  best  diagnosis  in  sight,  espe- 
cially as  there  are  some  points  in  the  case  suggesting  a  left-sided  hemi- 
plegia, for  the  combination  of  valvular  heart  disease  with  hemiplegia 
occurs  most  often  in  mitral  stenosis.  On  this  hypothesis,  the  leuko- 
cytosis will  be  explained  as  the  result  of  one  of  those  recrudescences  of 
fresh  infections  to  which  the  heart  of  mitral  stenosis  is  strikingly 
subject. 


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Case  264 


of 


Swollen  Arm 

CELLULITIS  ■■■^■■■■■IH^BHI^^^^^i^^  218 

CANCER  OF  THE  BREAST  ^^■■■■■■B  72 

LYMPHANGITIS  ^^aHBH  39 

THROMBOSIS  AND  PHLE--1  ^^^^^  26 

BITIS  i  ^^^^^ 

MEDIASTINAL  NEOPLASM  ■  4 


SWELLING   OF   THE   ARM  599 

That  no  arterial  embolism  of  the  arm  has  taken  place  seems  clear 
from  the  course  of  the  case.  The  obstruction,  if  there  be  any,  seems 
to  be  in  the  venous  trunks.  Since  no  mediastinal  pressure  has  made 
itself  manifest,  a  phlebitis  of  the  arm  confronts  is;  on  the  whole,  our 
best  explanation  of  the  fact. 

Outcome. — On  the  21st  the  white  cells  were  36,500.  The  arm  was 
nearly  normal  in  size  and  the  tenderness  was  very  slight.  The  general 
edema  persisted  after  the  arm  had  cleared  up. 

Case  265 

A  master  mariner  of  thirty-eight  entered  the  hospital  May  i,  1900. 
About  three  years  before  entrance  the  patient  noticed  a  lump  on  the 
outer  side  of  the  right  arm  near  the  shoulder.  After  a  few  weeks  it 
began  to  discharge  pus  and  two  or  three  months  later  healed  up.  A 
year  ago  the  discharge  again  appeared,  and  the  bunch  was  operated 
upon  by  Dr.  Maurice  H.  Richardson.  The  wound  healed  very 
quickly  this  time,  but  had  to  be  opened  again  in  three  weeks  and  has 
never  completely  healed  since  that  time.  The  last  operation  was  three 
months  ago.  Just  before  it  two  lumps  appeared  upon  the  left  leg,  one 
on  the  outer  side  of  it,  above  the  knee,  and  one  in  the  popliteal  space. 
These  lumps  were  opened,  but  the  latter  has  never  healed  and  is  very 
tender. 

Physical  examination  showed  fine  development  and  nutrition. 
There  was  a  small  discharging  sinus  in  the  region  of  the  right  deltoid, 
at  the  bottom  of  which ,  2  inches  from  the  surface,  no  sequestrum  could 
be  discovered.  The  function  of  the  arm  was  apparently  excellent. 
The  left  leg  was  considerably  swollen.  The  patient  says  that  at  times 
it  has  been  3  inches  larger  in  circumference  than  the  other,  just  above 
the  knee.  There  was  a  small  scar  on  the  outer  side  of  the  leg,  just  above 
the  knee,  where  the  patient  says  the  bunch  was  opened,  and  several 
old  white  circular  scars  about  the  knee  and  on  the  lower  leg.  There 
was  marked  edema  below  the  knee,  and  on  the  inner  side  of  it  a  brawny 
tender  swelling  connecting  with  the  popliteal  space,  where  a  shallow, 
unhealthy  looking  ulcer,  very  sensitive  to  touch,  was  discovered.  The 
motion  of  the  knee  was  good. 

The  leg  was  raised  on  pillows  and  the  swelling  gradually  de- 
clined. No  operation  was  done  either  on  the  leg  or  on  the  arm.  The 
patient  left  the  hospital  on  the  i8th  of  May  and  re-entered  October 
26,  191 1,  stating  that  he  had  been  operated  upon  in  this  hospital  thir- 
teen years  ago,  but  had  been  well  and  strong,  with  no  discomfort,  up 
to  the  time  of  the  present  illness,  two  weeks  ago,  when  he  began  to  have 


6oo  DIFFERENTIAL  DIAGNOSIS 

pain  in  the  outside  of  the  upper  right  arm,  near  the  seat  of  the  old 
operation.  It  all  came  in  one  night  and  now  causes  much  discomfort. 
Three  days  ago  the  whole  arm  became  much  swollen  and  tender  and 
the  patient  took  to  bed. 

Physical  examination  shows  in  the  upper  part  of  the  right  humerus 
a  dense  tumor,  red  and  very  tender,  the  size  of  half  an  orange ;  other- 
wise the  examination  was  negative. 

Discussion. — Everything  here  points  toward  a  local  rather  than  a 
circulatory  or  mediastinal  cause  for  the  edema.  In  all  probability 
the  lump  and  purulent  discharge  of  three  years  ago  was  due  to  an  osteo- 
myelitis of  the  humerus.  The  relapse  and  discouraging  course  of  the 
lesion  is  characteristic  of  osteomyelitis.  The  edema  which  occurred 
in  the  leg  at  the  same  time  was  doubtless  connected  with  the  scar 
formation  and  the  ulcer  in  the  popHteal  space. 

When  eleven  years  later  we  have  a  swelHng  of  the  arm  and  a  local 
tumor  over  the  humerus,  we  have  every  reason  to  connect  the  two  facts 
with  the  old  history.  Surely  we  must  be  dealing  with  an  osteomyelitis 
and  a  septic  edema  of  the  arm. 

Outcome. — The  tumor  was  opened  and  4  ounces  of  pus  evacuated. 
The  cavity  was  found  to  lead  to  the  bone,  which  was  cureted.  Four 
days  later  the  patient  was  discharged  to  the  Out-patient  Department. 
The  pus  contained  numerous  colonies  of  streptococci  and  staphylococci. 

Case  266 

A  candy  maker  of  fifty-five  entered  the  hospital  January  31,  191 1. 
The  patient's  father  died  of  gastric  cancer  at  seventy-two.  His  wife 
now  has  consumption,  otherwise  family  history  is  good.  General 
health  excellent.  He  had  typhoid  fever  twenty  years  ago.  Denies 
venereal  disease.  Eight  weeks  ago  his  left  wrist  swelled.  This  con- 
tinued for  about  forty  days.  Then  he  gave  up  work  and  the  symp- 
toms disappeared.  Three  days  ago  his  wrist  again  became  swollen, 
and  later  in  the  same  day  the  entire  arm  became  blue  and  considerably 
enlarged,  with  itching  at  the  shoulder.  He  has  no  fever  symptoms  and 
feels  well  in  all  respects. 

The  patient  did  not  look  sick  and  was  well  nourished.  In  the  left 
front  there  were  soft,  high-pitched,  interrupted  squeaks  and  twittering 
sounds,  otherwise  the  chest  was  negative;  likewise  the  abdomen.  The 
left  arm  and  adjacent  pectoral  region  were  moderately  swollen  and 
the  veins  over  the  shoulder  dilated.  X-ray  showed  nothing  abnormal. 
Wassermann  reaction  negative.  Blood  and  urine  negative.  Systohc 
blood-pressure,  135.     No  fever  in  four  days'  observation.     He  felt  so 


SWELLING   OF   THE   ARM  6oi 

well  that  at  the  end  of  this  period  he  left  the  hospital,  though  his  arm 
was  as  much  swollen  as  at  entrance. 

Discussion. — There  has  been  no  great  pain  and  no  local  lesion  sug- 
gesting sepsis.  The  general  condition  is  excellent.  Careful  search  for 
mediastinal  growths  and  sources  of  local  sepsis  is  negative.  Nothing 
is  left  but  phlebitis,  and,  although  we  have  no  idea  why  this  should 
occur,  we  need  not  expect  to  have  any  such  idea,  for  many  cases  of 
phlebitis  decline  to  furnish  us  with  any  explanation  of  their  cause. 
It  may  be  that  some  deeper-lying  malady  may  show  itself  in  the  later 
course  of  the  disease,  but  at  the  present  time  we  have  no  reason  to 
suspect  such  nor  to  connect  the  patient's  symptoms  with  his  old  typhoid 
fever.  The  pulmonary  signs  would  make  it  seem  that  the  lung,  as 
well  as  the  arm,  is  congested,  and  point  to  a  deep-seated  cause  such  as 
we  have  been  searching  for  unsuccessfully  in  the  mediastinum.  Until 
these  lung  signs  clear  up  there  must  be  some  anxiety  regarding  a  medi- 
astinal growth  or  aneurysm.  /i 

Outcome. — On  February  ii,  1911,  the  left  upper  arm  was  still  2 
inches  larger  in  circumference  than  the  right,  the  forearm  i  inch  larger 
than  the  right.  March  23,  191 1,  he  felt  perfectly  well.  The  arm  was 
unchanged. 

Case  267 

A  housewife  of  fifty  entered  the  hospital  June  23,  191 1.  The 
patient's  father  died  of  heart  trouble  at  sixty-nine.  Her  mother  is 
now  living,  but  has  heart  trouble,  otherwise  the  family  history  is 
good.  The  patient  has  never  had  rheumatic  fever  and  for  thirty 
years  has  had  no  tonsillitis.  Thirteen  years  ago,  after  the  dehvery  of 
her  second  child,  she  was  told  by  Dr.  Edward  Reynolds  that  she  had 
heart  trouble,  but  suffered  only  occasional  dyspnea  on  exertion  until 
three  years  ago,  when  the  dyspnea  became  more  marked  and  she 
began  to  have  precordial  pain  on  exertion  or  emotional  strain.  She 
was  told  at  that  time  that  her  heart  was  very  irregular,  and  she  re- 
members swelling  of  the  ankles  at  night  for  at  least  three  years. 

Four  weeks  ago  she  noticed  swelling  of  the  left  forearm,  which 
began  suddenly  without  other  symptoms.  This  was  coincident  with 
the  stopping  of  medicine  for  her  heart,  which  she  had  been  taking  for 
three  years.  On  account  of  the  arm  she  consulted  Dr.  Maurice  H. 
Richardson,  who  advised  ic-ray  and  sent  her  to  a  medical  man.  Her 
best  weight,  twenty  years  ago,  was  192  pounds.  Her  usual  weight 
now  is  180  pounds.  For  three  years  she  has  been  losing  weight,  and 
now  weighs  143  pounds,  without  clothes. 


6o2 


DIFFERENTIAL  DIAGNOSIS 


Physical  examination  showed  on  the  hard  palate  a  ridge  5  cm.  long, 
i^  cm.  wide,  and  -4  cm.  high  in  the  median  line,  apparently  bony.  She 
says  her  father  had  the  same  thing.  Heart's  apex  was  in  the  sixth 
space,  anterior  axillary  line,  where  a  systolic  and  presystoHc  murmur 
could  be  heard.  At  the  base  there  was  a  high-pitched  systoHc  and  a 
long  diastolic.  The  aortic  second  was  not  audible.  The  pulse  was  of 
the  plateau  tv-pe.  There  was  no  thrill.  The  vessels  of  the  neck  pul- 
sated strongly  and  the  pulse  could  be  felt  even  in  the  finger-tips,  where 
capillary  pulsation  was  visible  under  the  nails.  There  was  marked 
edema  of  the  left  upper  arm  and  hard  edema  of  the  forearm.  Both 
legs  were  also  much  swollen.  The  ,T-ray,  diagram  of  which  is  here  re- 
produced (Fig.   222),  showed  dilatation  of  the  aorta  along  its  left 

border,  Wassermann  reaction  was 
hueduiuv  hnc-  negative.  Blood  negative.  Blood- 
pressure,  220  mm.  Hg.,  systolic; 
no  mm.  Hg.,  diastolic.  Urine,  30 
ounces  in  twenty-four  hours,  with 
a  specific  gravity  of  1014,  a  very 
slight  trace  of  albumin,  no  casts. 

Discussion.  —  The    history 
sounds  rheumatic,  despite  the  pa- 
tient's statement  to  the  contrary. 
By  this  I  mean  that  it  is  unusual 
for  a  patient  to  have  a  recognized 
cardiac  lesion  for  thirteen  years 
unless  that  lesion  is  of  rheumatic 
origin.      Nevertheless,     there     is 
much  in   the   examination  of  the 
heart  and  aorta  pointing  toward 
syphilitic  disease.    Aortic  regurgi- 
tation and  enlarged  aortic  arch  may,  it  is  true,  result  merely  from 
rheumatic  trouble,  but  in  the  vast  majority  of  cases  they  are  syphilitic 
in  origin. 

Granting  that  the  aorta  is  dilated  and  capable  of  exerting  pressure 
upon  the  venous  trunk,  we  have  a  good  reason  for  phlebitis  and  swollen 
arm.  On  the  other  hand,  the  phlebitis  may  have  originated  simply 
by  infection  within  a  stagnating  venous  current  and  without  any  local 
pressure.  Nothing  in  the  case  tells  how  to  decide  this  question.  The 
prognosis  is,  in  all  probability,  good. 

Outcome. — The  cause  of  the  edema  was  not  discovered,  and  on 
July  6th  was  still  present,  though  much  less.  She  left  the  hospital 
July  loth. 


Fig.  222. — Sketch  of  .r-ray  plate  showing 
dilated  aorta  in  Case  267. 


SWELLING   OF   THE  ARM 


603 


Case  268 

A  laborer  of  thirty-seven  entered  the  hospital  May  23,  191 2. 
Family  history  negative.  Two  years  ago  he  had  left-sided  pneumonia 
followed  by  dry  pleurisy.  He  was  sick  ten  days,  and  thinks  he  has  not 
regained  his  strength  since.  He  had  bronchitis  six  months  ago,  but 
did  not  stop  work.  He  has  had  no  cough  this  winter.  Takes  one  to 
three  whiskies  a  day.  Denies  venereal  disease.  Seven  weeks  ago, 
while  at  work,  he  was  seized  suddenly  with  dyspnea,  vertigo,  and 
weakness.  After  a  drink  of  whisky  and  an  hour's  rest  he  managed 
to  finish  the  day's  work,  but  gave  up  next  day.     The  next  few  weeks 


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Fig.  223. — Chart  of  Case  268. 

he  was  up  and  about  the  house,  but  felt  poorly  and  did  no  work.  He 
thinks  he  had  fever  at  this  time,  but  noticed  no  shortness  of  breath. 

Three  weeks  ago  he  took  to  bed  with  pain  in  both  axillae,  so  severe 
that  he  could  only  lie  upon  the  "broad  of  his  back."  This  pain  has 
been  less  severe  of  late,  but  has  been  followed  by  shortness  of  breath 
and  orthopnea,  with  constant  cough,  but  very  little  sputa.  There  have 
been  no  digestive  symptoms  except  poor  appetite.  He  thinks  he  has 
lost  considerably  in  weight  and  strength. 

Physical  examination  showed  good  nutrition,  deep  rapid  breathing, 
severe  paroxysms  of  coughing.  He  lay  only  on  his  left  side.  Moderate 
cyanosis  and  marked  sweating.     No  glandular  enlargement.     Pupils 


6o4 


DIFFERENTIAL  DIAGNOSIS 


and  reflexes  normal.  Abdomen  negative.  The  heart-rate  was 
between  120  and  130  for  the  first  three  days  in  the  hospital  (Fig. 
223).  The  heart  sounds  were  feeble,  and  during  inspiration  many 
beats  were  nearly  or  completely  obliterated  at  the  wrist.  The  whole 
left  side  was  dull,  especially  in  the  upper  half,  and  there  were  many 
coarse  rales  over  it  and  over  the  precordia  as  well.  Fremitus  was 
generally  diminished  in  the  lower  half,  increased  in  the  upper  half. 
There  was  amphoric  breathing  under  the  left  clavicle.  The  right 
border  of  cardiac  dulness  extended  7  cm.  beyond  the  median  line. 
White  cells  were  11,500  at  entrance  and  remained  in  that  vicinity  for 
the  next  month.     The  urine  showed  nothing  abnormal  except  at 


Fig.  224. — Sketch  from  .r-ray  plate  June  4th. 


times  a  sKght  trace  of  albumin.  The  sputa  was  examined  repeatedly 
for  tubercle  bacilli,  but  they  were  never  found.  Among  the  various 
organisms  seen  pneumococci  predominated.  Dr.  F.  T.  Lord  con- 
sidered the  case  one  of  mediastinal  new  growth,  but  later  inclined 
toward  pericardial  effusion.  Dr.  W.  H.  Smith  considered  it  medias- 
tinal tumor.  Within  a  couple  of  days  of  entrance  a  very  marked 
edema  appeared  on  both  sides  of  the  neck,  also  a  massive  soft  edema  of 
the  tissues  in  the  region  of  the  left  breast.  The  right  arm  was  enor- 
mously swollen,  and  there  was  a  network  of  dilated  veins  over  the 
front  of  the  right  shoulder.  The  arm  was  also  tender  and  red,  so  that 
a  lymphangitis  was  suspected,  but  this  swelling  gradually  went  down 


SWELLING   OF   THE   ARM 


605 


without  interference.  On  the  28th  I  noted  that  the  dulness  in  the  left 
chest  was  nowhere  extreme,  but  moderate,  with  a  shade  of  tympany. 
The  breathing  was  bronchovesicular,  not  bronchial.  Rales  innumer- 
able, sharply  crackling.  The  patient  seemed  at  that  time  better. 
June  ist,  the  heart  sounds  were  clear  but  feeble,  the  arm  much  less 
swollen;  he  was  stronger  and  could  turn  in  bed  better.  The  cardio- 
hepatic  angle  was  still  markedly  obtuse.  In  the  left  back,  near  the 
angle  of  the  scapula,  and  in  the  lower  left  axilla  there  was  broncho- 
vesicular breathing  with  diminished  fremitus.  Above  that  point  the 
breathing  was  nearly  normal.     June  2d,  additional  history  was  ob- 


Fig.  225. — Sketch  from  a;-ray  plate  June  5th." 


tained  from  the  patient's  physician,  who  stated  that  the  patient 
had  been  drinking  heavily  before  the  onset  of  his  illness  and  that  there 
was  marked  precordial  pain  at  that  time;  that  three  weeks  ago  his 
present  dyspneic  condition  came  on,  together  with  pain  in  the  lower 
thorax.  At  that  time  signs  of  solidification  were  found  at  the  left  base, 
together  with  a  mitral  systoKc  murmur.  Under  the  physician's  obser- 
vation the  heart  sounds  changed  from  loud  and  strong  to  distant,  rapid, 
and  weak  in  the  course  of  seven  days.  X-ray  (Figs.  224,  225)  showed 
an  immense  shadow  filling  the  mediastinum,  much  wider  at  the  bottom 
than  at  the  top.  The  right  border  of  this  shadow  was  believed  to  be 
due  to  the  heart  and  great  vessels.     The  cardiohepatic  angle  was 


6o6  DIFFERENTIAL   DIAGNOSIS 

obliterated.  The  left  border  of  shadow  was  less  distinct,  but  suggested 
a  cardiac  outUne  more  than  anything  else.  Diagnosis,  probably  peri- 
cardial effusion,  possibly  dilated  heaTt.  June  1 2th  the  heart  showed  no 
murmur  and  had  a  feeble  tick-tack  quality.  Sounds  loudest  near  the 
ensiform.  The  edema  of  the  neck  had  then  disappeared,  but  was  still 
very  marked  in  the  tissues  about  the  left  nipple  and  axilla  and  in  the 
abdominal  wall.  June  14th  the  precordial  dulness  extended  18  cm, 
to  the  left  of  the  median  line  and  8  cm.  to  the  right  (Fig.  226). 
The  diagnosis  at  this  time  lay  between  pericardial  effusion  and  a 
dilated  heart,  with  intracardiac  thrombosis.     I  inclined  to  the  latter, 


Fig.  226. — Percussion  outlines  in  Case  268. 

but  as  the  man  was  getting  worse,  and  we  desired  to  exclude  the 
possibihty  that  his  decline  was  due  to  a  removable  pressure  about  the 
heart,  a  needle  was  injected  in  the  fifth  left  interspace,  i  cm.  inside  the 
nipple  line  at  right  angles  to  the  chest  wall.  No  fluid  was  obtained 
until  the  needle  had  passed  4!  cm.  and  had  traversed  a  firm,  resist- 
ant tissue.  Then  1400  c.c.  were  withdrawn  before  the  flow  stopped. 
Toward  the  end  there  was  a  marked  improvement  in  the  patient's 
pulse  and  a  faint  impulse  palpable  upon  the  cannula  with  each  heart- 
beat. The  last  500  c.c.  of  the  fluid  showed  a  slightly  reddish  tinge, 
the  rest  of  the  fluid  dark  straw  color.     The  specific  gravity  was  1020; 


SWELLING   OF   THE   ARM 


607 


albumin,  3^  per  cent.;  sediment:  polynuclears,  54  per  cent;  lympho- 
cytes, 46  per  cent.  Culture  showed  no  growth.  Twenty  minims  of 
the  sediment  injected  into  a  guinea-pig  June  14th.  July  19th  the  pig 
was  killed.  Autopsy  showed  tuberculous  lesions  of  the  glands,  liver, 
and  spleen.  In  reaching  this  fluid  the  needle  entered  at  a  point  15  cm. 
from  the  median  line,  though  it  was  inside  the  much  displaced  left 
nipple.  The  needle-point  was  directed  toward  the  median  line,  and 
entered  first  an  inch  of  solid  tissue,  then  went  more  easily,  then  pene- 
trated a  resisting  wall  and  reached  the  fluid.     During  the  tapping  the 


Fig.  227. — Percussion  outlines  and  other  signs  in  Case  2t 


right  border  of  cardiac  dulness  moved  considerably  toward  the  median 
line  and  the  paradoxic  pulse  disappeared.  Next  day  the  right  border 
of  dulness  was  3  cm.  nearer  the  middle  line  than  before  tapping.  The 
paradoxic  pulse  returned  soon  afterward  and  the  patient  was  much 
distressed  by  cough.  On  June  2  2d  the  bronchial  element  had  disap- 
peared from  the  left  chest  and  the  edema  was  gone.  He  moved 
strongly  in  bed,  his  pulse  was  slower  and  no  longer  paradoxic,  he  slept, 
without  drugs,  had  a  nearly  normal  temperature,  a  pulse  of  80,  and  was 
anxious  to  get  up.  On  June  29th  the  pericardium  seemed  to  be  re- 
filling.    The  outline  of  dulness  is  shown  in  Fig.  227.     July  3d  there 


6o8  DIFFERENTIAL  DIAGNOSIS 

was  a  sharp  pain  in  the  right  chest  and  a  friction  rub  was  heard  over 
the  upper  part  of  the  Hver  duhiess.  The  liver  now  reached  to  the  level 
of  the  umbilicus.  The  heart  sounds  were  again  distant.  X-ray  was 
interpreted  as  pericardial  effusion.  On  the  3d  of  July  he  had  a  sudden 
attack  of  collapse,  with  cold  extremities  and  almost  imperceptible 
pulse.  The  next  day  his  pericardium  was  tapped  at  the  same  part 
as  before  and  a  cavity  reached,  but  only  a  few  cubic  centimeters  of 
bloody  fluid  obtained.  There  was  no  flow  of  air  through  the  cannula 
with  respiration.  The  needle  was  beheved  to  be  in  the  pericardium. 
On  the  7th  he  began  to  have  bloody  sputa,  increasing  weakness,  and 
mental  confusion,  and  on  the  nth  he  died. 

Discussion. — Although  we  were  long  in  doubt  as  to  the  correct 
diagnosis  in  this  case,  we  finally  settled  down  upon  the  belief  that  peri- 
cardial effusion  was  the  most  important  element  in  it,  and  the  results 
of  paracentesis  confirmed  this.  Animal  inoculation  showed  that  the 
pericarditis  was  of  tuberculous  origin.  Although  he  had  been  so 
desperately  ill  throughout  the  whole  of  June,  it  seemed  toward  the  end 
of  that  month  as  if  he  were  going  to  get  well.  At  that  time  we  did  not 
know  the  result  of  the  animal  inoculation.  Presumably  he  had  tuber- 
culosis, not  only  in  his  pericardium,  but  elsewhere,  and  his  death  was 
due  not  only  to  cardiac  weakness,  but  to  infection. 

Edema  of  an  arm  in  connection  with  large  pericardial  effusions  has 
been  repeatedly  observed.  Presumably  in  this  case  it  was  due  to 
thrombosis  with  a  large  venous  trunk.  I  will  call  attention  to  the 
enormous  amount  of  fluid  withdrawn  from  his  pericardium,  which  cer- 
tainly must  have  been  gradually  distended  for  a  long  period  in  order 
to  contain  so  much. 

Case  269 

An  Italian  housewife  of  fifty- three  entered  the  hospital  April  25, 
191 2.  The  patient  has  six  healthy  children  and  has  had  no  miscar- 
riages. For  a  long  time  she  has  noticed  dyspnea  on  exertion  and  can- 
not climb  stairs.  Otherwise  she  has  been  well.  She  takes  a  little 
wine,  but  not  every  day,  and  no  hard  liquor.  For  the  past  month, 
since  she  has  been  in  this  country,  she  has  been  in  bed  with  increased 
dyspnea,  swelling  of  the  feet,  of  the  left  arm,  and  of  the  abdomen. 
Her  appetite  remains  good  and  she  feels  well  in  other  respects. 

Physical  examination  showed  emaciation  and  enormous  enlarge- 
ment of  the  abdomen.  Pupils  and  reflexes  normal.  Heart's  impulse 
in  the  fifth  space  in  the  nipple  Une.  Sounds  rapid  and  irregular; 
no  murmur.     Pulmonic  second  accentuated.     Artery  walls  palpable. 


SWELLING   OF   THE   ARM  609 

Lungs  show  coarse  rales  throughout.  Abdomen  showed  shifting 
duhiess  in  the  flanks  and  the  suggestion  of  a  mass  in  the  right  upper 
quadrant.  Very  marked  edema  of  the  legs.  Urine,  25  ounces  in 
twenty-four  hours,  with  a  specific  gravity  of  1020  and  occasional  hya- 
line casts.  Blood  normal.  Blood-pressure  was  essentially  normal. 
Wassermann  reaction  negative.  The  feces  contained  an  8-inch  round 
worm,  otherwise  not  remarkable.  The  abdomen  was  tapped  and 
46  ounces  of  pale  yellow  fluid  obtained,  with  a  specific  gravity  of  1009, 
and  the  sediment  containing  46  per  cent,  endothelial  cells  and  the 
remainder  lymphocytes.  On  account  of  the  low  gravity  of  the  fluid, 
without  evidence  of  cardiac  or  renal  disease,  a  diagnosis  of  cirrhosis  of 
the  liver  was  made,  but  within  four  days  the  liver  edge  could  be  easily 
felt.  After  tapping,  it  receded  rapidly  and  the  heart  continued  to  be 
irregular  in  force  and  rhythm.  Mitral  stenosis  was,  therefore,  sug- 
gested. May  5th  the  arhythmia  continued  absolute.  The  pulmonic 
second  accentuated,  the  first  sound  sharp.  The  disproportionate 
ascites,  in  comparison  with  the  edema  elsewhere,  suggested  adherent 
pericardium.  Calomel,  3  gr.  every  four  hours,  was  given  May  8th, 
after  digipuratum,  diuretin  and  purgation,  and  salt-free  diet  had 
failed  to  increase  the  output  of  urine.  After  the  calomel  had  been  con- 
tinued for  three  days  it  was  omitted.  On  the  next  day  40  ounces  of 
urine  were  passed  and  the  dropsy  rapidly  subsided.  May  27th  there 
was  no  ascites  or  edema.  The  heart  was  slow  and  regular,  the  first 
sound  doubled,  and  a  slight  presystolic  murmur  was  heard  at  the  apex. 
The  edge  of  the  liver  was  still  palpable,  but  smooth,  and  even  at  the  time 
of  discharge,  June  3d,  the  organ  extended  to  the  level  of  the  umbilicus, 
but  its  dulness  began  at  the  costal  margin.  She  left  the  hospital  June 
13d,  but  re-entered  June  12th,  with  a  return  of  all  the  symptoms.  The 
day  after  this  second  entry  she  was  exceedingly  nauseated.  Every 
other  beat  of  the  heart  was  strong,  the  intermediary  beat  not  reaching 
the  wrist  and  being  followed  by  a  compensatory  pause. 

Discussion. — No  one  could  be  blamed  for  making,  as  we  did,  a 
diagnosis  of  cirrhosis  during  the  early  stage  of  this  patient's  illness, 
although  we  were  quite  aware  that  some  cardiac  disease  existed  in  addi- 
tion to  the  liver  trouble.  With  the  prompt. recession  of  the  liver  edge, 
this  diagnosis  began  to  seem  very  improbable. 

What  causes  for  ascites  remain?  The  tap-fluid  was  obviously  a 
transudate  or  dropsical  effusion.  It  could  not  be  explained  by  tuber- 
culous peritonitis  or  neoplasm  of  the  peritoneum.  The  kidneys  showed 
too  little  disease  to  explain  it.  We  must  fall  back,  therefore,  upon  the 
heart  as  the  cause  of  ascites.     Now,  the  one  cardiac  lesion  which  we 

Vol.  11—39 


6lO  DIFFERENTIAL   DIAGNOSIS 

have  grown  to  recognize  as  a  cause  of  ascites  without  any  proportionate 
degree  of  edema  in  the  legs  is  adherent  pericardium.  This  disease 
ultimately  becomes  associated  with  a  capsular  Hver  cirrhosis  and  leads 
to  many  a  mistaken  diagnosis  in  interstitial  hepatitis. 

The  presystolic  murmur  and  cardiac  irregularity  may  well  have  been 
due,  as  we  supposed,  to  mitral  stenosis,  a  lesion  not  infrequently  com- 
bined with  pericardial  adhesions. 

So  far  I  have  said  nothing  whatever  regarding  the  swollen  arm. 
Presumably,  it  is  due  to  phlebitis. 

Outcome. — The  patient  began  to  be  much  disturbed  mentally, 
refused  medicines  with  violence,  and  could  not  be  quieted.  She  left 
the  hospital  on  the  i6th. 

Case  270 

With  an  uneventful  history  and  inheritance  a  clerk  of  forty-six 
entered  the  hospital  June  lo,  191 2,  complaining  that  about  two  months 
ago  both  hands  became  rather  suddenly  swollen,  the  skin  red,  rough, 
and  covered  with  cracks  and  scales.  There  was  only  slight  itching  and 
no  known  exposure  to  local  irritants.  He  felt  otherwise  well,  but  had 
to  stop  work  because  of  the  appearance  of  his  hands,  and  since  that  has 
been  steadily  losing  weight  and  strength.  His  appetite  is  gone,  and 
he  hves  on  eggs,  milk,  and  bread.  He  has  a  constant  dull  pain  in  the 
upper  abdomen,  without  relation  to  food.  His  bowels  are  slightly  loose, 
moving  twice  a  day.  His  flow  of  saliva  is  increased,  especially  at 
night,  and  he  has  a  bad  taste  in  his  mouth.  On  exertion  he  is  short  of 
breath  and  his  feet  swell  during  the  day.  His  head  feels  dizzy  and  his 
eyesight  is  poor.     He  passes  urine  once  or  twice  in  the  night. 

Physical  examination  shows  poor  nutrition,  swelling  of  both  hands 
and  wrists,  with  a  patchy  deep  red  coloration  and  some  small  whitish 
areas  where  the  epidermis  has  come  off,  leaving  a  clear  surface  beneath. 
Small  exfoliating  areas  are  seen  near  the  nasal  fold  on  each  side.  The 
abdomen  shows  slight  tenderness  and  spasm,  especially  in  the  epigas- 
trium. Physical  examination,  including  blood  and  urine,  otherwise 
normal.  Systolic  blood-pressure,  no.  No  fever  in  two  weeks'  ob- 
servation. Stomach- tube  shows  no  contents  in  the  fasting  stomach 
and  no  free  HCl  after  a  test-meal.  The  patient  states  that  for  several 
years  he  has  had  attacks  of  indigestion  in  the  springtime,  lasting  a  day 
or  two,  but  never  severe  enough  to  be  remembered  without  cross- 
questioning.  With  the  onset  of  his  present  skin  lesions  there  was 
loss  of  appetite,  soreness  of  the  mouth,  and  a  mild  diarrhea.  He  has 
also  had  tingling  sensations  in  his  legs  and  feet,  relieved  by  rubbing. 


SWELLING   OF   THE   ARM  6ll 

When  seen  in  the  Out-patient  Department  there  seemed  to  be  a 
noticeable  disturbance  in  mentaHty:  excitement,  emotionalism,  and 
weakness.  The  skin  lesion  consists  of  a  dry,  cool  eczema  of  the  hands 
and  wrists,  i  to  4  cm.  above  the  wrist- joint.  Underneath  a  ring,  re- 
moved by  the  patient  July  13th,  the  skin  is  fresh  and  soft. 

Discussion. — Although  both  arms  were  involved  in  this  case,  I  have 
included  it  because  of  its  unusual  diagnostic  interest.  Clearly  the 
edema  is  to  be  attributed  not  to  intravascular  or  mediastinal  causes, 
but  to  the  local  lesion.  The  association  of  this  with  diarrhea,  indi- 
gestion, and  mental  symptoms  strongly  suggests  pellagra.  Indeed,  I 
know  of  no  other  diagnosis  which  can  be  called  upon  to  explain  such  a 
clinical  picture.  If  any  other  diagnosis  is  made,  we  have  to  suppose 
that  there  are  two  or  more  separate  diseases,  such  as  eczema  and 
dementia  paralytica.  We  have  no  evidence  of  this,  and  should  en- 
deavor, if  possible,  to  bring  all  the  facts  under  a  single  explanation. 

Outcome. — The  patient  was  seen  by  Dr.  C.  P.  Ward,  of  Atlanta, 
who  found  no  doubt  of  the  diagnosis  of  pellagra.  Investigation  of  the 
patient's  home  conditions  showed  that  he  was  peculiar,  and  could 
not  get  along  with  his  neighbors  or  employers.  He  says  that  he  is 
always  trying  to  spit  poison  out  of  his  mouth.  There  was  nothing  pe- 
culiar about  his  diet,  and  no  reason  to  believe  that  he  had  partaken 
of  any  spoiled  cereals.     He  was  discharged  on  the  24th  of  July. 


CHAPTER  XVI 

DELIRIUM 

It  is  hard  to  deline  delirium.  Ordinarily,  we  are  content  to  say 
that  it  is  the  sort  of  rambling,  incoherent  talk  which  patients  have 
during  the  height  of  pneumonia  or  in  acute  alcoholism;  but  we  also 
recognize  that  in  insanity  the  same  phenomena  occur  without  any 
infection  or  fever.  We  distinguish  dehrium  from  the  irrational,  in- 
coherent talk  of  the  psychoneurotic  or  the  hysteric.  The  latter  pa- 
tients put  more  of  will  and  intention  into  what  they  say.  The  truly 
delirious  patient  is  thought  of  as  entirely  unaware  of  what  he  is  say- 
ing. Whether  these  distinctions  can  be  strictly  maintained  or  not, 
the  foregoing  is  probably  as  definite  a  statement  of  our  present  usage 
of  the  word  dehrium  as  can  easily  be  made. 

Using  the  word  in  this  sense,  we  must  note,  first  of  all,  that  children 
become  delirious  on  very  sUght  provocation,  as  the  result  of  a  cold 
or  even  a  digestive  upset.  In  them  the  phenomenon  is  doubtless  in 
some  way  connected  with  their  greater  liabihty  to  sleep  walking 
and  to  talking  in  their  sleep.  Their  mental  stabihty  and  balance  is 
more  easily  disturbed  than  that  of  the  adult. 
I  Next  to  the  transitory  deliria  of  the  slight  childhood  illnesses, 

'V  alcoholic  deliriu?n,  or  delirium  tremens,  is  probably  the  most  com- 
mon. This  is  often  characterized  by  hallucinations  of  sight.  Animals, 
and  especially  black  animals,  are,  more  frequently  seen  than  other 
objects. 

Among  infectious  diseases,  pneumonia  is  most  often  associated 
with  dehrium  of  an  active  type.  In  typhoid  the  dehrium  is  quieter 
and  the  patient  is  easily  roused  from  it.       i_jL_::^  .:  .' 


;  Of  special  interest  are  the  postinfectious   deliria  and  psychoses, 

^         which  are  to  be  differentiated  from  most  other  acute  psychoses  by 

their   better   prognosis.     Doubtless    these   are   closely   akin   to   the 

psychoses  of  the  exhaustion  type  seen  after  surgical  operations,  and 

often  called  postoperative  psychoses. 
'  In  uremic  states  and  in  cerebral  arteriosclerosis  one  sees  various 

types  of  mental  disturbance,  and  in  the  acuter  and  more  serious  forms 

typical  delirium  may  be  present. 
612 


-i 


DELIRIUM  613 

During  the  treatment  of  a  case  of  acute  rheumatism,  and  in  any 
other  disease  which  involves  the  free  exhibition  of  salicylates,  one 
must  remember  that  these  salts  are  capable  of  exciting  an  active 
delirium,  the  source  of  which  is  often  not  recognized.  Next  to  sali- 
cylates, belladonna  is  the  commonest  source  of  a  drug  delirium. 

In  acute  anemia,  after  hemorrhage  and  shock,  periods  of  delirium 
are  often  seen,  not  only  in  fatal  cases,  but  in  many  that  recover. 

All  of  the  above  types  of  delirium  are  to  be  distinguished  from 
those  which  occur  in  the  course  of  those  chronic  psychoses  to  which 
we  give  collectively  the  name  of  " insanity"  and  of  which  I  shall  not 
attempt  to  speak.  For  practical  purposes,  it  seems  to  me  that  it  is 
especially  important  that  the  physician  should  be  able  to  distinguish 
true  delirium  from  the  manifestat:ions  of  hysteria.  This  distinction 
is  aided  by  every  observation  which  helps  us  to  recognize  the  other 
features  of  hysteria:  the  cause  and  mode  of  onset,  the  previously 
recognized  characteristics  of  the  patient,  the  association  with  con- 
vulsive or  pseudocomatose  states,  the  presence  of  hemianesthesia, 
and  other  stigmata  of  hysteria.  So  far  as  the  delirium  itself  is  con- 
cerned, it  is  distinguished  from  the  incoherence  of  the  hysteric  in 
that  the  latter  has  usually  a  predominance  of  emotion,  and  especially 
of  rapidly  shifting  emotion.  The  hysteric  can  usually  be  aroused, 
that  is,  made  to  talk  with  comparative  rationality  if  the  appropriate 
stimulus  can  be  appKed.  The  older  and  more  brutal  way  of  applying 
this  stimulus  was  to  throw  a  bucket  of  water  over  the  sufferer.  Often, 
however,  the  right  appeal  to  the  patient's  central  or  true  personality 
can  be  found  and  used  by  one  intimate  with  the  patient.  In  true 
dehrium  this  is  impossible,  and  nothing  that  we  say  makes  any  special 
difference. 

Case  271 

An  Italian  laborer  of  twenty-one  entered  the  hospital  November 
16,  1 91 2,  in  delirium;  no  history  was  obtained.  The  patient  was 
poorly  nourished,  and  had  a  curious  contraction  of  his  facial  muscles, 
suggesting  risus  sardonicus.  The  left  pupil  was  much  larger  than 
the  right.  Both  were  circular,  but  reacted  only  slightly  to  Hght. 
Accommodation  could  not  be  tried.  The  tongue  was  not  seen  on 
account  of  trismus,  possibly  voluntary.  The  epitrochlear  glands 
were  felt,  but  there  was  no  demonstrable  enlargement  of  any  gland. 
The  heart  was  negative,  the  pulse  not  dicrotic.  The  lungs  negative. 
The  abdomen  level,  tympanitic,  held  somewhat  rigidly;  no  other 
abnormality.     The  spleen  was  definitely  enlarged  to  percussion,  but 


6i4 


DIFFERENTIAL  DIAGNOSIS 


its  edge  not  felt,  perhaps  on  account  of  muscular  spasm.  The  lower 
end  of  the  right  kidney  was  palpable,  but  not  tender.  There  was  no 
costovertebral  tenderness.  Knee-jerks  were  not  obtained.  There 
was  no  ankle-clonus  or  Babinski.  Kernig's  sign  was  questionable 
on  both  sides;  the  neck  was  not  stiff.  There  was  no  bone  or  muscle 
tenderness. 

The  Widal  reaction  was  suggestive,  but  not  positive.  Blood- 
culture  negative.  Wassermann  reaction  negative.  Leukocytes,  6900; 
polynuclears,  88  per  cent.;  lymphocytes,  12  per  cent.  Temperature 
as  in  Fig.  228.  The  amount  of  urine  could  not  be 
determined,  as  it  was  passed  involuntarily.  The 
specific  gravity  was  1024;  albumin,  slight  trace.  A 
few  granular  casts  and  red  blood-corpuscles  were 
found  in  the  sediment.  The  spinal  cord  was  tapped 
and  10  c.c.  of  blood-tinged  fluid  withdrawn  under 
slight  pressure.  On  account  of  the  admixture  of 
blood,  examination  of  the  sediment  was  unsatis- 
factory. Fundus  oculi  was  normal,  the  cornea 
coated  with  a  film  of  mucous  secretion.  A  slight 
amount  of  bloody  and  purulent  sputum  was  ob- 
tained which,  on  examination,  showed  nothing  sig- 
nificant.    No  diagnosis  as  yet. 

November  i8th  a  sister-in-law  was  communicated 
with,  who  stated  that  the  onset  of  the  dsease  had 
been  sudden,  with  pains  all  over  the  body,  especially 
in   the  back  of   the  neck,   elbow-joints,  and  knee- 
joints.     These  symptoms  began  with  a  chill  nine 
days  ago.     The  patient  is  unmarried  and  has  been 
in  this  country  two  years. 
The   cultures   from   the   spinal  fluid  were  negative.     A   second 
attempt  at  spinal  puncture  was  unsuccessful.     The  needle  seemed 
to  be  in  the  spinal  canal,  but  no  fluid  was  obtained. 

Discussion. — Clearly,  this  is  the  delirium  of  an  infectious  disease. 
The  only  question  is,  what  infection?  The  curious  contraction  of 
facial  muscles  made  us  fear  tetanus,  but  as  time  went  on  this  disap- 
peared and  nothing  else  appeared  to  suggest  that  disease.  Had  the 
Widal  reaction  been  positive,  one  would  have  no  hesitation  in  calling 
the  case  one  of  typhoid  fever,  although  the  increased  percentage  of 
polynuclear  cells  and  the  absence  of  any  leukopenia  are  atypical  for 
typhoid.  Nothing  in  the  examination  of  the  nervous  system  sup- 
ports the  idea  of  meningitis. 


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Case  271. 


DELIRIUM  .  615 

The  sudden  onset  with  chill  might  have  occurred  in  malaria,  but 
we  searched  without  success  for  any  parasites.  Up  to  the  19th  of 
November  our  diagnosis  was  wholly  uncertain. 

Outcome. — Gn  the  19th  a  number  of  red  macules  and  papules, 
about  2  mm.  in  diameter,  appeared  upon  the  trunk  and  abdomen  and 
the  Widal  reaction  in  the  blood  was  positive.  The  patient  was  con- 
stantly delirious  and  noisy.  On  the  21st  a  third  attempt  was  made 
at  spinal  puncture  without  success.  The  patient  died  the  same  night. 
Autopsy  showed  the  lesions  of  typhoid  fever  with  double  otitis  media 
and  focal  pneumonia  of  the  left  lung.  In  the  pelvis  of  the  left  kid- 
ney was  a  stone  occluding  the  ureter  and  producing  hydronephrosis. 
The  other  kidney  was  normal.    Chronic  perihepatitis  and  perisplenitis. 

Case  272 

A  merchant  of  fifty-five  was  seen  in  consultation  December  11,  1 9 1 2 . 
He  had  always  been  well,  although  nervous,  until  ten  days  ago,  when 
he  had  chill  and  fever,  rusty  sputum,  and  the  ordinary  signs  of  solidi- 
fication at  the  right  base.  For  five  days  he  continued  desperately  ill, 
then  his  temperature  dropped  to  normal,  but,  to  the  surprise  of  all  con- 
cerned, he  began  then  to  be  delirious,  and  has  continued  so  ever  since 
despite  a  persistent  normal  temperature.  The  pulse  has  ranged  be- 
tween 100  and  1 20,  and  has  at  times  been  very  irregular.  He  has  taken 
food  well,  but  has  had  moderate  abdominal  distention  throughout 
the  illness. 

At  the  onset  of  his  delirium  he  had  incontinence  of  feces.  He 
has  now  regained  control  of  the  sphincter.  The  attending  physicians 
are  in  doubt  as  to  the  condition  present  at  the  bottom  of  the  right 
lung. 

On  examination  the  patient  is  drowsy  and  has  respirations  still, 
40  per  minute,  formerly  48.  He  looks  more  than  his  age,  but  at  the 
time  of  the  examination  was  rational  when  aroused  from  his  nap. 
He  moves  with  difficulty  and  seems  greatly  prostrated.  At  the  top 
of  the  right  lung,  as  low  as  the  level  of  the  second  rib,  there  is  flatness 
on  percussion,  with  distant  bronchial  breathing.  In  the  back  this  is 
accompanied  by  coarse  crackling  rales,  which  are  more  numerous  in 
the  lower  half  of  the  lung.  Below  the  level  of  the  second  rib  in  front 
the  percussion  note  is  short,  but  low  pitched,  with  a  shade  of  tym- 
pany. The  left  lung  showed  nothing  but  a  few  scattered  rales;  the 
pulse  is  100  and  regular.  The  heart  is  negative.  The  blood-pressure 
is  not  measured.  Save  for  moderate  abdominal  distention  the  phys- 
ical examination  is  otherwise  negative. 


6l6  DIFFERENTIAL   DIAGNOSIS 

Discussion. — Meningitis  had  been  seriously  considered  by  the 
attending  physicians,  but  against  this  was  the  absence  of  any  stiff  neck, 
Kernig's  sign,  or  ocular  changes.  The  absence  of  headache  and  fever, 
at  the  time  when  cerebral  symptoms  were  most  marked,  suffices,  with 
the  other  data  just  mentioned,  to  exclude  meningitis. 

Were  he  an  alcoholic,  one  might  have  interpreted  the  deHrium 
as  dehrium  tremens,  even  though  no  trembling  was  present  to  sub- 
stantiate the  title;  but  the  history  was  reliable  and  excluded  this 
possibility.  The  condition  was  clearly  not  a  hysteric  one.  At  his 
age  such  things  do  not  arise  de  novo. 

The  ordinary  psychoses  are  not  apt  to  arise  in  such  close  connec- 
tion with  an  infectious  disease.  Hence,  the  remaining  possibiHty — 
postinfectious  delirium — seemed  the  most  reasonable  diagnosis.  This 
was  explained  to  the  family  and  a  good  prognosis  was  given. 

Outcome. — February  25,  1913,  the  patient  writes  that  he  is 
perfectly  well  in  essential  respects,  although  he  has  been  somewhat 
slow  in  recovering  his  strength.  The  attending  physician  tells  me 
that  the  delirium  cleared  up  about  a  week  after  I  saw  him. 

Case  273 

A  farm  laborer  of  advanced  years  consulted  his  dentist  early  in 
March  for  a  supposed  toothache  on  the  left  side  of  the  upper  jaw. 
The  dentist  pulled  two  teeth  without  relieving  the  pain,  which  later 
spread  over  the  left  side  of  the  head  and  was  specially  severe  at  the 
vertex.  At  this  time  the  patient  had  no  other  symptom  except  an 
increasing  weakness  and  confusion,  which  did  not  prevent  him,  how- 
ever, from  continuing  to  do  his  work  upon  a  farm,  though  many  of  his 
days  were  short  ones.  About  six  weeks  after  the  onset  of  headache  he 
returned  one  day  from  his  work  in  a  state  of  mind  which  alarmed  his 
wife.  He  did  not  seem  to  recognize  her  and  talked  wildly  and  inco- 
herently. He  was  removed  to  the  nearest  hospital  the  same  night, 
where  I  saw  him  next  day. 

He  was  mumbling  and  rambling  in  his  talk  as  I  approached  his 
bedside.  As  he  was  an  old  friend  of  mine,  I  spoke  his  name  sharply, 
at  which  he  roused,  recognized  me,  and  burst  into  tears,  evidently 
affected  by  the  contrast  between  his  present  condition  and  the  ruddy 
health  in  which  I  had  always  met  him  before.  The  left  pupil  was  much 
larger  than  the  right;  the  tongue  was  protruded  somewhat  toward 
the  right  side  of  the  mouth.  The  right  knee-jerk  was  increased, 
and  there  was  a  Babinski  reaction  in  the  right  foot.  During  a  week's 
observation  there  was  no  fever  or  leukocytosis.     Wassermann  reac- 


DELIRIUM  617 

tion  was  not  tried.  His  speech,  as  he  responded  to  my  questions, 
was  slow  and  difficult  to  understand.  Single  words  were  repeated 
monotonously,  and  before  I  left  him  he  drifted  off  again  into  inco- 
herent talk.  The  systoHc  blood-pressure  was  180.  The  heart  was 
somewhat  enlarged,  but  not  otherwise  remarkable.  There  were  many 
crackling  rales  scattered  in  both  backs.  The  fundus  oculi,  examined 
by  an  expert  on  the  previous  night,  showed  no  important  changes, 
though  the  arteries  were  markedly  sclerosed,  as  were  those  in  the  arm 
and  groin.  He  no  longer  complained  of  headache,  but  became  more 
and  more  helpless  and  hemiplegic.  Three  days  later  his  sphincters 
became  relaxed,  and  on  the  fourth  day  he  died.  There  was  no 
autopsy. 

Discussion. — At  this  patient's  advanced  age  it  is  natural  to  at- 
tribute almost  any  cerebral  symptoms  to  arteriosclerosis.  Brain 
tumor  is  almost  the  only  plausible  alternative.  The  absence  of  more 
distinct  focal  changes  and  of  optic  neuritis  and  the  presence  of  hemi- 
plegia are  more  characteristic  of  arteriosclerotic  brain  trouble  than 
of  tumor. 

The  chief  point  of  interest  in  the  case  is  the  onset  with  delirium, 
rather  than  with  aphasia  or  coma.  Just  what  went  on  within  his 
brain  we  never  shall  know.  It  seems  to  me  probable  that  throm- 
bosis and  softening  were  the  cause  both  of  his  initial  headache  and  of 
his  subsequent  delirium. 

Case  274 

On  the  1 8th  of  February,  19 13,  I  saw  in  consultation  a  married 
woman  of  thirty,  who  had  always  been  perfectly  well  except  for  an 
attack  of  t5rphoid  fever  twelve  years  before. 

For  the  past  two  months  she  has  been  somewhat  run  down.  Febru- 
ary 12  th  she  was  taken  with  sore  throat  and  pain  in  the  left  side  of  the 
chest,  a  temperature  of  103.5°  F.,  pulse  160.  The  tonsils  showed  the 
ordinary  appearance  of  follicular  tonsillitis,  but  the  amount  of  pain 
was  unusual.  By  the  15th  the  throat  was  much  better,  temperature 
101°  F.,  but  the  doctor  noticed  at  this  time  a  peculiar  odor,  suggesting 
that  of  the  postmortem  room. 

Next  morning,  February  i6th,  she  woke  in  active  delirium,  with 
religious  delusions,  with  bad  pulse,  a  scanty  urine,  yet  with  a  tempera- 
ture of  only  99.5°  F.  During  the  next  twelve  hours  only  10  ounces  of 
urine  were  passed,  although  she  was  taking  food  very  fairly  and  com- 
plaining of  no  headache  or  other  form  of  distress.  No  atropin  or  bella- 
donna had  been  given  her.     She  had  received  aspirin,  5  gr.,  three  times 


6i8 


DIFFERENTIAL  DIAGNOSIS 


a  day,  and  infusions  of  digitalis,  |  ounce,  every  four  hours  for  the  past 
three  days,  with  strychnin,  -^V  gr.,  four  times  a  day. 

On  examination  she  showed  good  color  and  nutrition.  Teeth  and 
chin  like  those  of  a  rabbit.  She  lay  upon  her  back  with  closed  eyes, 
twitching  eyelids,  and  hands  tightly  clasped  across  her  chest.  Her 
breathing  was  slow  and  regular,  her  heart-beats  60  to  the  minute,  with 
a  slight  irregularity  apparently  of  the  sinus  t^q^e.  Save  for  a  systolic 
murmur  at  the  apex  the  heart  was  otherwise  negative,  likewise  the 

lungs  and  abdomen.  The  neck  was  not 
stiff.  The  reflexes  were  excellent.  The 
pupils  were  large,  equal,  and  reacted 
normally. 

When  I  saw  her  the  patient  was  con- 
scious and  would  put  out  her  tongue 
and  answer  simple  questions,  but  showed 
no  initiative.  Her  temperature  and 
pulse  ranged  as  in  Fig.  229.  Subse- 
quent conversation  with  her  husband 
elicited  the  fact  that  in  the  previous 
summer,  while  away  from  home  and  her 
two  children,  she  had  become  acutely 
homesick,  and  after  her  return  remained 
still  morbid  and  not  as  bright  as  before. 
Just  before  the  present  illness  there  had 
been  some  question  of  her  going  away 
from  home  a  second  time.  About  this 
time  she  had  been  greatly  upset. 
Discussion. — Meningitis  can  be  easily  excluded  by  the  absence 
of  physical  signs  ordinarily  associated  with  it.  Uremia  had  been 
seriously  considered  by  the  attending  physician,  but  when  I  saw  her 
the  urine  was  normal  in  quality  though  diminished  in  amount,  and 
warranted  no  such  diagnosis.  There  was  a  good  deal  in  the  physical 
state  when  I  first  saw  her  to  suggest  hysteria.  The  character  of  her 
previous  delirium,  and  the  immediate  sequence  of  her  mental  symp- 
toms upon  the  fall  of  temperature  during  an  acute  infection,  seemed  to 
me  to  warrant  the  diagnosis  of  a  postfebrile  psychosis. 

Suspicion  of  more  serious  mental  derangement,  based  upon  her 
previous  attack  of  homesickness  and  morbidity,  did  not  seem  to  me 
well  founded. 

Outcome. — On  February  27th  her  physician  reported  that  she  had 
steadily  improved  since  the  i8th  and  was  now  in  excellent  condition. 


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Fig.  229. — Chart  of  Case  274. 


DELIRIUM  619 

Case  275 

On  the  27th  of  February,  19 13,  a  girl  of  nineteen  was  seen  in  con- 
sultation with  her  attending  physician.  Although  always  anemic  and 
irregular  in  her  menstruation,  she  had  been  considered  a  healthy,  bright 
girl  until  two  weeks  ago.     Her  family  history  was  excellent. 

Two  weeks  ago  she  had  a  normal  appendix  removed.  The  con- 
valescence seemed,  for  the  first  ten  days,  perfect.  There  was  no  fever 
or  other  untoward  symptom.  Then  appeared  what  the  doctor  called 
"insanity"  and  headache.  Her  motions  were  largely  resistive  and  ster- 
eotyped, a  favorite  action  being  to  start  up  with  the  remark,  "I've  got 
to  go  and  meet  the  doctor."  She  was  disoriented  and  recognized  no 
one.  At  times  she  seemed  to  be  Hving  over  again  the  experiences  of 
the  etherization.  Thus  she  would  say,  "They  make  you  He  still  and 
tell  you  to  breathe  deep,"  etc.  At  other  times  she  would  say,  "Sh-sh- 
sh,"  with  a  sendistammering  articulation,  as  if  trying  to  form  words. 
Again  she  was  tearful  and  anxious,  grasping  the  doctor's  hand  and 
asking,  "Are  you  mad  with  me?  You  are  not  mad  with  me,  are  you?" 
The  words  and  motions  just  referred  to  had  been  repeated  again  and 
again,  day  and  night,  for  the  past  five  days. 

Physical  examination  showed  pallor;  hemoglobin,  65  per  cent.;  a 
negative  chest  and  abdomen,  save  for  some  tympany  in  the  latter. 
The  legs  were  spastic,  and  showed  at  times  a  coarse  tremor  approaching 
clonus.  The  eyes  and  neck  seemed  normal  and  there  was  no  paralysis. 
The  fundus  examination  had  previously  been  made  and  was  negative. 
The  chart  showed  absolutely  no  fever  and  the  leukocytes  were  not 
elevated.  Her  only  complaint  was  the  pounding  sensation  at  the 
base  of  her  skull  on  the  left  side,  and  it  was  remembered  that  she  had 
had  trouble  with  her  ear  for  a  long  time,  and  had  complained  at  times  of 
deafness,  although  at  other  times  this  was  wholly  absent,  and  she  said 
only  that  she  felt  as  if  something  were  growing  in  her  ear. 

During  the  five  days  that  have  passed  since  the  abnormal  mental 
condition  first  showed  itself  she  has  slept  hardly  at  all  and  eaten  but 
little,  refusing  food  for  the  most  part.  The  systematization  of  her  de- 
lusions, as  above  described,  has  been  most  marked  in  the  last  two  days; 
off  and  on  she  seems  quite  normal,  but  if  she  chances  to  sleep  a  httle 
she  always  wakes  "insane."  To  speak  sharply  to  her  often  rouses 
her  and  makes  her  for  the  time  being  quite  normal. 

From  time  to  time  throughout  these  five  days  she  has  breathed 
with  great  rapidity,  but  has  had  no  cough  or  true  dyspnea.  She  moves 
easily  and  strongly  in  bed  and  has  had  no  incontinence  of  urine  or  feces. 
The  urine  is  normal. 


620  DIFFERENTIAL  DIAGNOSIS 

Discussion. — Meningitis  can  be  ruled  out  by  the  absence  of  fever 
and  leukocytosis.  The  tendency  to  resistance  and  stereotypy  makes 
it  necessary  to  consider  dementia  praecox,  but  no  such  diagnosis  is 
warranted  until  a  longer  time  has  elapsed.  This  is  something  to  fear, 
and  not  yet  to  exclude.  The  onset  of  the  symptoms  immediately  after 
the  operation  gives  ground  for  doubting  whether  anything  so  serious  is 
present. 

The  tendency  to  live  over  again  the  experiences  of  etherization  is 
what  one  might  expect  in  hysteria,  and  the  physical  condition  is  quite 
consistent  with  that  idea;  but,  if  it  is  true  that  she  has  previously  been 
a  perfectly  normal  girl  and  these  symptoms  never  appeared  until  after 
the  operation,  it  seems  to  me  more  reasonable  to  make  some  diagnosis 
which  can  be  connected  directly  or  indirectly  with  the  operation  itself. 
Two  possibilities  suggest  themselves :  since  she  is  a  chlorotic  she  is  more 
than  ordinarily  Hable  to  cerebral  thrombosis  (sinus-thrombosis),  and 
since  any  type  of  thrombosis  is  more  apt  to  happen  after  an  opera- 
tion, such  a  lesion  might  conceivably  have  occurred.  Against  this, 
however,  are  the  absence  of  all  focal  symptoms,  unless  the  sense  of 
pounding  in  the  back  of  the  head  is  taken  as  such,  which  would  be,  I 
think,  a  mistake. 

On  the  whole,  the  most  reasonable  diagnosis  seems  to  me  that  of  an 
exhaustion  psychosis  or  postoperative  psychosis,  such  as  is  the  terror  of 
all  surgeons  who  remember  its  possibility.  Nevertheless,  the  majority 
of  such  psychoses  entirely  clear  up,  and  a  good  prognosis  may,  therefore, 
be  given  in  such  cases. 

Outcome. — A  letter  received  from  her  doctor  states  that  "on  the 
loth  of  March,  at  ii  p.  m.,  she  said  she  felt  something  wind  up  in  her 
head  and  then  break,  and  immediately  her  reason  came  back  and  she 
recognized  every  one  who  came  into  the  room.  After  that  she  com- 
plained of  headache,  especially  at  the  back  of  the  head,  and  would  often 
throw  her  head  back  with  a  jerk  and  arch  her  back.  I  gave  her  a  good 
talking  to,  told  her  she  must  stop  it,  which  she  did,  although  her  neck 
was  quite  lame  for  some  time  after  that.  She  is  now  perfectly  well 
mentally.  She  gets  up  each  day  and  practices  walking,  although  her 
legs  are  so  weak  that  she  can  scarcely  use  them.  She  looks  fin^  and 
has  no  temperature." 

Remarks. — This  outcome  seems  to  suggest  that  hysteria  was  the 
correct  diagnosis — hysteria  of  the  postoperative  t3rpe — but  I  should 
still  be  doubtful  of  it  unless  some  history  of  previous  attacks  or  mani- 
festations can  be  obtained. 


DELIRIUM  621 

Case  276 

In  the  spring  of  1893  a  patient  was  brought  in  a  cab  to  the  Massa- 
chusetts General  Hospital,  fighting  maniacally  with  his  companion. 
This  was  about  5  p.  m.  His  companion  stated  that  the  patient  had 
been  apparently  perfectly  well  and  at  work  as  a  day  laborer  that  same 
day  at  noon,  when,  without  rhyme  or  reason,  he  suddenly  went  crazy, 
and  after  some  delay  was  conveyed  to  the  hospital.  After  being  put 
to  bed  he  soon  became  manageable,  and  slept  a  good  deal  of  the  evening 
as  well  as  the  night.  His  temperature  was  103.5°  F.  at  entrance.  His 
pulse  was  not  elevated,  respiration  normal.  His  leukocytes  were  not 
increased.  The  only  abnormal  feature  of  the  physical  examination 
was  a  palpable  spleen.  A  preliminary  diagnosis  of  typhoid  fever  was 
made.  No  Widal  reaction  was  done,  because  in  1893  Widal  had  not  as 
yet  done  his  epoch-making  work.  The  next  morning  the  temperature 
was  normal  and  the  patient  seemed  dazed,  otherwise  almost  well.  This 
sudden  transition  set  us  to  hunting  for  malarial  organisms  in  the  blood, 
and  after  an  hour's  search  I  was  able  to  find  a  pigmented  parasite  in 
violent  motion.  Quinin  was  at  once  administered  in  large  doses,  and 
the  patient  was  able  to  leave  the  hospital  twenty-four  hours  later. 

Discussion. — The  case  illustrates  the  clinical  manifestations  of  that 
overcrowding  of  the  cerebral  capillaries  with  malarial  parasites  which  is 
so  familiar  to  students  of  tropical  medicine  who  see  autopsies  in  the  per- 
nicious forms  of  the  disease.  Almost  any  type  of  cerebral  or  mental  dis- 
ease, such  as  meningitis,  apoplexy,  or  insanity,  may  thus  be  simulated 
by  a  malarial  infection,  and  whenever  the  temperature  is  high  and  the 
leukocytes  low  in  such  a  case  one  should  do  one's  best  to  find  a  malarial 
parasite. 


CHAPTER  XVII 

PALPITATION  AND  ARHYTHMIA 

A  NORMAL  man  is  unconscious  of  his  heart-beat  except  after  violent 
exertion  or  in  periods  of  emotional  strain.  If  he  becomes  oppressively 
conscious  of  it  at  other  times  he  has  palpitation.  The  heart's  action 
may  be  irregular  or  simply  forcible  and  rapid. 

Usually  palpitation  and  arhythmia  go  together,  that  is  to  say,  the 
heart-beat  is  especially  noticed  by  the  patient  when  it  becomes  irregular. 
Mere  force  in  the  heart-beat,  especially  if  it  has  been  worked  up  to 
gradually  during  the  development  of  cardiac  hypertrophy,  is  not  often 
noticed  by  the  patient.  What  is  distressing  is  a  sudden  change  in 
force  or  in  rhythm,  which  is  forced  upon  the  patient's  attention  and  in 
greater  or  less  degree  alarms  him.  When  a  patient  comes  to  us  for 
palpitation  he  usually  has  one  of  the  following  diseases: 

(i)  Thyrotoxicosis,  in  which  the  violence  as  well  as  the  rapidity  of 
the  heart's  action  attracts  the  patient's  attention  and  causes  alarm. 
There  is  probably  no  disease  in  which  we  see  such  violent,  noisy,  and 
spectacular  heart  action  as  in  the  thyroid  intoxications  with  which 
Graves'  name  is  ordinarily  associated. 

I  recently  saw  a  patient  who,  in  answer  to  my  preliminary  ques- 
tions as  to  what  ailed  her,  simply  pointed  to  her  violently  jump- 
ing carotids  and  said,  ''Don't  you  see?"  That  was  her  malady,  so 
far  as  she  knew.  Examination  showed  the  ordinary  signs  of  a 
thyroid  intoxication. 

(2)  Hypertension,  due  to  arteriosclerosis  or  to  chronic  nephritis. 
Sooner  or  later  in  this  condition  the  patient  is  aware  of  violent  beating 
and  throbbing,  especially  at  night,  when  his  attention  is  not  otherwise 
occupied,  or  when  he  stoops  and  then  rapidly  recovers  his  balance,  or 
after  meals. 

(3)  Valvular  heart  disease,  without  hypertension,  but  with  arhyth- 
mia. 

(4)  Arhythmia,  with  or  without  gross  cardiac  disease. 

Of  the  irregularities  seen  clinically  in  patients  with  obvious  cardiac 
failure,  60  per  cent,  are  due  to  auricular  fibrillation,  and  have  the 
characteristics  ordinarily  described  as  absolute  or  perpetual  arhyth- 
622 


PALPITATION   AND   ARHYTHMIA  623 

mia  (Thomas  Lewis).     Taking  all  varieties  of  irregular  heart,  with 
or  without  cardiac  failure,  Lewis  gives  the  following  figures : 

Auricular  fibrillation 40  per  cent. 

Premature  contractions 35         " 

Paroxysmal  tachycardia,  sinus  arhythmia,  heart-block,  flutter, 

and  alternation 15         " 

The  most  serious  types  of  arhythmia  are  due  to  auricular  fibrilla- 
tion. The  premature  contractions  are  much  less  often  of  ominous 
significance.  The  latter  type  corresponds  to  the  occasional  skipping 
of  a  beat,  either  at  regular  intervals  or  as  an  isolated  phenomenon. 
It  may  continue  through  life  and  give  little  or  no  trouble.  The  arhyth- 
mia caused  by  auricular  fibrillation  produces  a  pulse  in  which  no  two 
successive  beats  are  alike.  When  it  once  begins  it  usually  continues 
during  the  rest  of  the  patient's  life,  though  that  is  not  always  the 
case. 

Sinus  arhythmia  means  ordinarily  the  physiologic  variation  of  the 
heart's  rate  in  connection  with  the  act  of  breathing.  The  heart  goes 
more  slowly  during  inspiration  and  more  rapidly  during  expiration. 
Li  adolescence  and  in  the  nervous,  this  psychologic  variation  may  be 
exaggerated,  but  it  does  not  usually  trouble  the  patient  or  lead  him 
to  consult  a  physician. 

Most  premature  contractions  can  be  recognized  clinically  by  the 
fact  that  they  are  followed  by  a  pause  of  such  a  length  that  the  pre- 
mature contraction  plus  the  pause  is  almost  exactly  equal  in  time  to 
two  normal  contractions. 

Heart-block  is  to  be  suspected  clinically  in  cases  of  very  slow 
pulse — 25  to  30  or  thereabouts — whether  or  not  this  is  associated 
with  apoplectic  seizures.  A  certain  diagnosis  cannot  be  made  with- 
out tracings  from  the  jugular  bulb  and  from  the  radial  simultaneously. 

Paroxysmal  tachycardia  can  usually  be  recognized  by  the  extremely 
rapid  rate  of  the  heart — 200  or  thereabouts — without  any  disturbances 
of  rhythm  and  without  any  serious  interference  with  circulation. 
When  the  rate  is  much  above  200  the  name  of  "auricular  flutter"  is 
given  to  it. 

Alternation  means  the  interposition  of  a  small  wave  between  each 
two  larger  ones,  with  or  without  a  disturbance  of  rhythm.  It  is  to 
be  distinguished  from  coupling  of  the  heart-beats,  in  which  there  is  a 
pause  between  each  pair  of  cardiac  contractions.  Alternation  can 
rarely  be  recognized  without  a  radial  pulse  tracing. 


624  DIFFERENTIAL  DIAGNOSIS 

ETIOLOGY 

Among  the  causes  of  arkythmia  we  may  mention:  (a)  A  failing 
heart  of  any  typt,  rheumatic,  syphilitic,  arteriosclerotic,  or  nephritic; 
{h)  the  presence  of  any  of  the  above  diseases  in  the  heart,  without 
cardiac  failure';  (c)  drugs,  especially  tobacco;  id)  nervous  influences. 

Of  the  four  well-recognized  types  of  arhythmia,  only  two  are 
often  noticed  by  the  patient — namely,  the  premature  contraction  or 
extra  systole  and  the  absolute  or  perpetual  type  of  arhythmia.  The 
sinus  irregularities  of  adolescence  are  seldom  noticed  unless  they  are 
greatly  exaggerated  by  some  neurotic  condition  or  by  bad  hygiene. 
The  most  marked  cases  of  this  kind  are  usually  in  those  who  have 
subjected  themselves  to  sexual  excesses  without  venereal  disease. 
Tobacco  and  alcohol  and  coffee  play  a  much  smaller  part  in  rendering 
the  heart  and  the  patient  so  irritable  that  sinus  irregularities — that  is, 
the  variations  in  rate  which  are  associated  with  respiration — become 
troublesome.  Heart-block  is  so  rare  an  affection  that  it  need  not  be 
further  mentioned  here. 

SUMMARY 

For  practical  purposes,  then,  we  may  say  that  a  person  who  com- 
plains of  palpitation  suffers  in  the  vast  majority  of  cases  either  from 
thyrotoxicosis,  from  hypertension,  chronic  valvular  disease,  from 
an  absolute  arhythmia,  however  produced,  or  from  frequent  pre- 
mature contractions  of  the  heart. 

The  pause  following  the  latter  type  of  irregularity  is  usually  the 
thing  which  most  alarms  the  patient.  It  often  awakens  him  from 
sleep  with  a  sense  of  falling  or  of  great  apprehension,  sometimes  of 
suffocation,  although  the  circulation  is  perfectly  well  performed  in  the 
vast  majority  of  such  cases. 

In  the  types  of  palpitation  associated  with  valvular  disease  this 
particular  symptom  is  usually  overshadowed  by  dyspnea,  insomnia, 
and  other  manifestations  of  the  same  lesions;  hence,  there  are  really 
but  three  conditions  in  which  the  patient  often  consults  us  for  palpi- 
tation: thyrotoxicosis,  h3q)ertension,  and  nervous  states. 

Case  277 

A  Russian  housewife  of  fifty-two  entered  the  hospital  April  21, 
1906.  Last  winter  the  patient  began  to  notice  attacks  of  palpita- 
tion of  short  duration,  occurring  every  week  or  two.  Lately  the 
attacks  have  been  more  frequent;  otherwise  she  has  always  been  well 
and  has  an  excellent  family  history. 


Types  of  Cardiac  Disease 


BOTH  SEXES 


RHEUMATIC 
NEPHRITIC 
ARTERIOSCLEROTIC 
SYPHILITIC 
DOUBTFUL  CASES 
GOITER  HEART 

RHEUMATIC 
NEPHRITIC 
ARTERIOSCLEROTIC 
SYPHILITIC 
DOUBTFUL  CASES 
GOITER  HEART 

RHEUMATIC 
NEPHRITIC 
ARTERIOSCLEROTIC 
SYPHILITIC 
DOUBTFUL  CASES 
GOITER  HEART 


MALES  ALONE 


FEMALES  ALONE 


278 

117 

93 

74 

30 

8 

108 
59 
53 
52 
19 
2 

170 
58 
40 
22 
11 
6 


PALPITATION   AND   ARHYTHMIA  625 

Physical' examination,  save  as  relates  to  the  heart,  was  negative. 
The  heart's  dulness  extended  |  inch  outside  the  nipple  line  in  the  fifth 
space.  Its  action  was  irregular  and  intermittent.  A  soft  systolic 
murmur  was  occasionally  heard  at  the  apex.  Blood  and  urine  nega- 
tive. It  was  later  learned  that  she  had  been  taking  six  to  ten  cups 
of  tea  a  day.  After  a  week's  observation,  the  pulse  ranging  most  of 
the  time  between  80  and  90,  she  was  allowed  to  leave  the  ward,  al- 
though the  heart  was  still  slightly  irregular. 

Discussion. — I  have  searched  the  best  I  can  through  hospital  records 
and  private  records  for  a  case  illustrating  a  cardiac  neurosis  with  pal- 
pitation as  a  result  of  excessive  tea-drinking.  This  is  the  best  case 
that  I  can  find,  yet  it  does  not  seem  to  me  that  it  will  bear  criticism. 
It  is  notable  that  no  blood-pressure  measurement  is  recorded,  but 
my  impression  is  that  it  would  have  been  found  to  be  elevated.  The 
persistence  of  the  irregularity  after  a  week's  separation  between  the 
patient  and  her  tea  seems  to  me  to  make  it  improbable  that  the  tea 
was  really  the  cause  of  her  heart  trouble.  It  is  not  at  all  Ukely  that 
she  has  but  recently  begun  to  drink  an  excess  of  tea,  yet  at  the  age 
of  fifty-two  she  is  able  to  say  that  her  troubles  have  lasted  less  than  a 
year.  A  cardiac  trouble,  showing  itself  for  the  first  time  at  the 
age  of  fifty-two  and  associated  with  enlargement,  intermittance, 
and  irregularity,  seems  to  me,  in  all  probabiUty,  due  to  some  organic 
disease,  of  which,  in  the  present  instance,  arteriosclerosis  or  nephritis 
seem  the  most  probable  causes.  The  Wassermann  reaction  should, 
of  course,  be  done. 

Case  278 

A  Swedish  musician  of  twenty-one  entered  the  hospital  June  10, 
191 1.  The  patient's  family  history  is  excellent,  previous  history 
also  good,  save  for  an  occasional  attack  of  tonsilKtis,  the  last  one 
February,  191 1.  Once  or  twice  in  the  past  summer  she  spat  up  a 
mouthful  of  pink  sputa;  no  cough  before  or  after.  She  now  comes 
to  the  hospital  on  account  of  rapid  heart  which  she  has  noticed  for 
two  months,  at  first  only  on  exertion,  but  now  even  when  she  is  quiet. 
She  also  feels  weak  and  cannot  walk  as  she  did.  She  has  to  He  down 
in  the  afternoon.  Her  appetite,  bowels,  and  sleep  are  normal  and  she 
has  lost  no  weight.  Her  eyes  have  not  become  more  prominent,  and 
her  collars  have  grown  too  large  rather  than  too  small.  She  is  very 
fond  of  music,  but  because  of  expense  has  not  been  able  to  continue 
her  studies  on  the  violin  for  the  past  year,  and  this  has  been  a  source 
of  worry  and  anxiety. 

Vol.  11—40 


626 


DIFFERENTIAL  DIAGNOSIS 


Physical  examination  showed  good  nutrition,  no  tremor  of  the 
hands,  thyroid  normal,  systolic  blood-pressure  no,  heart  negative, 
except  for  a  rapid  rate,  130  per  minute,  lungs  and  abdomen  negative. 
Reflexes  normal.  Blood  and  urine  normal.  No  fever  in  three  weeks' 
observation.  With  rest  and  reassurance,  an  occasional  hypnotic  or 
laxative,  the  patient  gradually  improved.  Subcutaneous  injections 
of  tuberculin,  in  doses  increased  i  to  5  mg.,  were  not  followed  by  any 
characteristic  reaction.  The  pulse  gradually  diminished  in  rate 
(Fig.  230).     On  the  26th  she  was  allowed  to  go  home. 

Discussion. — Save  for  the  rapid 
gain  under  treatment  and  the  rapid 
diminution  in  the  rate  of  the  pulse, 
one  might  easily  believe  this 
woman  to  be  suffering  from 
Graves'  disease,  which  sometimes 
begins  with  tachycardia  and  no 
other  symptoms  except  nervous- 
ness. But  it  does  not  seem  to  me 
at  all  probable  that  any  such 
trouble  would  quiet  down  within 
a  week.  As  a  rule,  months  of  rest 
are  necessary  before  much  change 
is  to  be  seen. 

Since  the  heart  at  present 
shows  nothing  abnormal  except 
its  rate,  and  since  it  settles  down 
with  rest,  one  cannot  well  assume 
that  any  of  the  four  tjqDes  of 
cardiac  disease — rheumatic,  syphilitic,  arteriosclerotic,  or  nephritic — 
is  present.  The  tonsillitis  of  February,  191 1,  and  the  pink  sputa  of 
the  past  summer  may  indicate  some  more  serious  trouble,  but  at  the 
present  time  I  do  not  see  that  we  have  any  proof  of  it. 

In  all  probability,  therefore,  we  must  attribute  the  heart-hurry  to 
nervous  or  moral  causes,  and  continue  in  this  belief  until  more  con- 
vincing evidence  of  organic  disease  appears. 

Case  279 

A  maid  of  twenty-five  entered  the  hospital  October  30,  191 1.  The 
patient  has  always  been  well  except  for  acute  indigestion,  which 
troubled  her  three  years  ago  for  a  short  time.  During  the  past  sum- 
mer she  was  again  nauseated  in  the  hot  nights  and  vomited  a  few 


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Fig.  230. — Chart  of  Case  278. 


PALPITATION   AND   ARHYTHMIA  627 

times.  She  has  always  been  strong  and  cheerful  and  has  liked  her 
work.     Her  menstruation  has  been  normal,  her  habits  good. 

A  week  ago  she  felt  a  queer  sensation  of  pressure  over  the  heart 
during  the  afternoon.  At  one  o'clock  the  next  morning  she  awoke 
with  sHght  nausea  and  heaviness  in  the  precordia.  She  vomited 
almost  at  once,  and  was  immediately  relieved  "of  a  load  of  sickness 
around  the  heart,"  but  at  the  same  time  noticed  that  the  heart  began 
to  beat  with  great  rapidity,  and  this  continued  the  rest  of  the  night 
and  all  the  next  day,  the  pumping  distressing  her  very  much.  Dur- 
ing this  time  she  had  brief  spells  of  nausea,  relieved  by  vomiting, 
about  every  hour.  The  next  night  she  slept  and  did  not  notice  the 
rapid  heart  action.  The  day  after  that  she  felt  weak  but  comfortable, 
and  on  the  third  day  was  up  and  felt  well.  That  night  (two  nights 
ago)  the  heart  began  to  pound  again,  and  has  continued  at  top  speed 
ever  since.  She  has  remained  in  bed,  feeling  weak,  sleeping  little, 
but  otherwise  not  uncomfortable.  If  she  sits  up  she  feels  faint  and 
dizzy.  Apparently  there  was  no  emotional  stress  of  any  kind  at  the 
time  of  the  onset  of  these  symptoms. 

Physical  examination  showed  a  healthy,  well-nourished  girl,  in 
profuse  perspiration,  with  sHght  general  tremor.  Pupils  and  reflexes 
negative,  except  the  left  knee-jerk  was  more  Uvely  than  the  right. 
The  rate  of  the  heart  when  counted  at  the  apex  was  about  200.  At 
the  wrist  it  could  not  be  accurately  counted.  The  apex  impulse 
was  in  the  fifth  space,  i  cm.  inside  the  nipple  line.  The  sounds  were 
very  slightly  irregular  in  force  and  rhythm.  There  were  no  murmurs. 
Physical  examination,  including  the  urine,  was  otherwise  negative. 
Blood  at  entrance  showed  15,500  white  cells,  60  per  cent,  of  which 
were  lymphocytes.     Systolic  blood-pressure,  105  mm.  Hg. 

Discussion. — There  is  nothing  distinctive  or  definite  about  the 
case  until  we  come  to  recognize  the  degree  of  tachycardia.  A  pulse- 
rate  of  200,  without  considerable  arhy  thmia  or  signs  of  decompensation, 
rarely  means  anything  else  than  paroxysmal  tachycardia.  A  heart 
seriously  weakened  by  any  of  the  ordinary  causes  of  heart  disease  or  by 
the  toxins  of  infection  never  goes  at  such  a  rate  in  an  adult.  Its  ra- 
pidity, therefore,  is  really  an  encouraging  sign.  The  diagnosis  can  be 
clinched  beyond  reasonable  doubt  only  in  case  the  tachycardia  ceases 
as  suddenly  as  it  began  and  leaves  the  patient  in  fairly  good  health. 

A  case  of  thyrotoxicosis  with  a  heart  of  anything  like  this  rapidity 
would  be  in  extremis.  This  patient  is  far  too  comfortable.  The  ner- 
vous and  organic  types  of  cardiac  malady  practically  never  send  the 
heart-rate  beyond  160.     Paroxysmal  tachycardia  may  come  on  in  fuU 


628  DIFFERENTIAL   DIAGNOSIS 

health  as  the  result  of  some  trifling,  often  quite  unrecognizable,  cause; 
thus,  I  have  seen  it  in  a  young  girl  at  the  time  of  menstruation  without 
any  important  consequences  beyond  a  few  hours'  discomfort. 

It  may  also  appear  in  a  heart  previously  weakened  by  disease,  but 
only  under  these  conditions  has  it  any  grave  significance.  Even  then 
the  patient  never  dies  during  such  an  attack,  and  often  enjoys  many 
years  of  good  health  thereafter. 

Outcome. — Two  hours  after  entrance  the  pulse  was  found  to  be  90, 
and  continued  slow  during  the  four  days  of  her  stay  in  the  hospital. 
Most  of  the  time  its  rate  was  between  65  and  75.  She  was  entirely 
free  from  symptoms;  her  blood  was  normal,  and  she  was  accordingly 
allowed  to  go  home. 

Case  280 

A  bookkeeper  of  twenty- three  entered  the  hospital  October  10, 1911. 
For  two  years  he  has  been  troubled  with  attacks  of  palpitation  and 
nervousness.  He  has  never  been  sick  before.  His  habits  are  excellent. 
His  family  history  is  good.  At  first  the  palpitation  came  after  meals  or 
during  excitement,  but  the  attacks  have  grown  steadily  more  frequent 
and  longer.  During  his  worst  attacks  he  feels  weak  and  unsteady  upon 
his  legs,  but  has  no  dyspnea.  A  year  ago  an  attack  took  him  just  as  he 
was  starting  for  a  quarter-mile  race,  but  he  ran  the  quarter  in  fifty-four 
seconds.  He  has  a  constant  vague  sense  of  uneasiness  and  restlessness. 
Small  incidents  often  cause  much  emotional  reaction,  and  when  alone 
in  a  crowd  he  has  a  curious  sense  of  fear.  Before  the  present  illness  he 
is  quite  sure  that  he  was  a  matter-of-fact  person,  never  nervous  or  self- 
conscious.  He  has  had  several  long  vacations  without  benefit,  but 
usually  feels  better  on  Mondays.  His  appetite,  bowels,  and  sleep  are 
normal.  He  has  no  fatigue  and  does  his  work  as  well  as  ever,  although 
for  the  past  year  there  have  been  brief  sensations  of  hotness  followed  by 
chilliness  and  he  has  noticed  a  trembling  of  his  fingers. 

Physical  examination  showed  a  slight  symmetric  enlargement  of  the 
thyroid,  coarse  tremor  of  the  fingers,  normal  viscera,  no  exophthalmos. 
Normal  blood  and  urine.  Weight,  140  pounds.  Pulse  at  entrance  1 10, 
but  after  that  it  ranged  between  70  and  90,  although  he  was  not  kept 
in  bed. 

Discussion. — Evidently  there  is  a  strong  nervous  element  in  this 
case,  but  the  presence  of  enlarged  thyroid  and  tremor  of  the  fingers 
makes  it  clear  that  the  nervousness  is  of  thyroid  origin  and  the  palpi- 
tation from  the  same  source.  Presumably,  there  was  a  time  in  the 
progress  of  this  case  when  rapid  heart  action  and  nervousness  were  its 


PALPITATION   AND   ARHYTHMIA  629 

only  symptoms,  i.  e.,  when  no  tremor  or  goiter  were  visible.  At  such  a 
time  one  could  only  make  the  diagnosis  by  the  exclusion  of  all  other 
possibilities.     In  nervous  people  this  is  sometimes  impossible. 

Outcome. — Operation  was  considered,  but  decided  against.  He  left 
the  hospital  October  14th.  In  the  spring  of  1913  the  patient  reported 
that  he  was  a  little  better,  but  still  unable  to  do  his  regular  work.  Ner- 
vous tension,  especially  in  cities  or  crowds,  bothers  him  so  much  he  says 
he  would  walk  a  mile  to  avoid  it.  In  the  country  he  is  practically  all 
right  unless  upset  by  some  unusual  excitement.  When  at  rest  he  feels 
fine,  but  during  periods  of  heart-hurry  may  get  into  a  panicky  state, 
especially  if  alone  at  night.  His  pulse  is  now  84,  hands  warm  and  moist. 
His  weight  is  140  pounds,  as  it  has  been  for  the  past  four  years. 

Case  281 

An  Italian  housewife  of  thirty-one  entered  the  hospital  October 
21,  191 1.  The  patient's  illness  dates  from  four  months  previously. 
She  has  never  been  sick  before  this  and  has  an  excellent  family  history. 
Four  months  ago  she  began  to  be  troubled  with  palpitation  and  weak- 
ness, and  these  symptoms  have  persisted  since.  Shortness  of  breath  is 
scarcely,  if  at  all,  present,  but  during  the  first  three  months  of  this  pe- 
riod she  had  much  headache  and  almost  daily  vomiting,  immediately 
after  meals.  She  had  no  edema  at  any  time.  A  month  ago  she  was 
delivered  of  a  9^-pound  baby  by  an  easy  labor,  but  immediately  after 
it  had  urgent  dyspnea  and  much  aggravated  palpitation.  The  baby 
died  a  week  later.  The  patient  remained  in  bed  ten  days,  then  was  up 
until  the  past  week,  when  she  has  again  remained  in  bed,  still  vomiting 
occasionally,  but  nearly  free  from  headache.  A  week  ago,  and  again 
last  night,  she  had  an  attack  of  violent  palpitation  and  could  not  get 
her  breath.     She  has  had  no  dizziness  or  fainting,  no  cough  or  edema. 

Physical  examination  showed  poor  nutrition,  rapid  breathing,  slight 
cyanosis,  normal  pupils  and  reflexes,  slight  glandular  enlargement  in  the 
neck,  axillae,  and  groins. 

The  heart's  impulse  was  forcible  and  diffuse,  extending  4  cm.  out- 
side the  nipple,  in  the  fifth  space.  There  was  no  demonstrable  enlarge- 
ment to  the  right  and  no  thrill  palpable.  A  rough,  loud,  systoHc  mur- 
mur was  heard  over  the  whole  precordia,  loudest  at  the  apex,  trans- 
mitted to  the  axilla  and  back.  A  faint  diastoHc  whift"  was  also  occa- 
sionally heard  along  the  left  border  of  the  sternum.  The  pulmonic 
second  sound  was  moderately  accentuated.  SystoHc  blood-pressure 
varied  between  105  and  125  mm.  Hg;  diastolic  between  80  and  95  mm. 
Hg.     Blood  and  urine  were  normal.     Lungs  and  abdomen  negative. 


630  DIFFERENTIAL   DIAGNOSIS 

No  temperature  during  a  week's  observation.  At  times  a  low-pitched 
presystolic  murmur  was  heard  at  the  apex  and  there  was  an  occasional 
complaint  of  precordial  pain,  but  in  most  respects  compensation  seemed 
to  be  excellent.  No  digitahs  was  given,  and  the  patient  went  home  on 
the  27th.     No  Wassermann  test  was  made. 

Discussion. — Physical  signs  point  strongly  toward  valvular  dis- 
ease, and  probably  toward  mitral  stenosis.  The  patient  is  too  young 
for  arteriosclerosis,  shows  no  signs  of  nephritis  or  thyrotoxicosis,  and 
has  never  had  a  heart  sufficiently  rapid  to  be  called  paroxysmal  tachy- 
cardia. The  unusual  feature  about  the  case  is  that  she  should  have 
been  troubled  first  and  chiefly  by  palpitation  instead  of  by  dyspnea. 
The  prognosis  in  such  a  case  is  good,  as  she  has  got  by  the  dangerous 
years  for  rheumatic  heart.  With  moderately  good  care  she  ought  to 
live  for  many  years,  provided  her  heart  trouble  is,  as  I  have  assumed, 
rheumatic  and  not  syphilitic.  A  Wassermann  test  would  help  to 
determine  the  prognosis. 

Case  282 

A  woman  of  fifty-five  entered  the  hospital  January  16,  191 2.  The 
patient's  mother  died  of  shock,  one  sister  at  sixty  of  apoplexy,  and 
another  sister  at  forty  of  shock.  Two  brothers  died  of  consumption. 
The  patient's  husband  had  a  tuberculous  throat,  and  died  of  a  com- 
bination of  this  and  what  was  called  typhoid  fever.  She  has  three 
children  hving  and  well  and  has  had  one  miscarriage.  Twenty  years 
ago  she  had  sciatica,  which  was  obstinate  and  painful  for  two  years, 
but  entirely  left  her  after  that  time. 

For  the  past  six  years  she  has  had  occasional  pains  in  her  knees  and 
hands,  accompanied  in  the  latter  site  by  swelling  and  redness.  For 
the  past  two  years  there  have  been  no  acute  symptoms  in  the  fingers, 
but  stiffness  and  bony  enlargement  have  been  noticed.  She  had  ner- 
vous prostration  twenty  years  ago.  She  passed  the  menopause  thirteen 
years  ago  without  incident.  One  year  ago  she  had  a  bad  cough,  lasting 
six  weeks,  but  without  hemoptysis,  night-sweats,  or  loss  of  weight. 

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and  oppression  in  the  chest,  accompanying  sensations  of  dyspnea. 
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bowels  obstinately  constipated.  She  has  become  weak  and  indifferent. 
She  sleeps  well  with  one  pillow.  Eight  months  ago  she  weighed  172 
pounds,  with  clothes;  now,  166  pounds,  without  clothes. 

Physical  examination  showed  good  nutrition,  flushed  cheeks,  puffy 


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PALPITATION   AND   ARHYTHMIA  63 1 

Ward— „Hosp.  No.- 


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Fig.  231. — Blood  chart  of  Case  282. 


632  DIFFERENTIAL   DIAGNOSIS 

eyelids,  a  few  urticarial  wheals  in  the  left  upper  chest.  Pupils  slightly- 
irregular,  equal,  and  reacting  normally.  Heart's  apex  extends  i  cm. 
outside  the  nipple.  There  Avas  a  soft  systolic  murmur  over  the  entire 
precordia,  transmitted  to  the  axilla.  The  pulmonic  second  sound  was 
accentuated.  Systolic  blood-pressure,  140  mm.  Hg.  at  entrance,  de- 
clining after  a  week  to  120,  where  it  stayed.  Lungs  were  negative, 
except  for  a  few  line  rales  at  the  right  base  behind.  Liver  dulness 
extended  from  the  fifth  space  to  a  point  3  cm.  below  the  costal  margin 
in  the  mammary  Hne,  where  a  smooth  non- tender  edge  was  felt;  other- 
wise the  abdomen  was  negative.  There  was  edema  of  ankles  and 
over  the  sacrum.  Knee-jerks  present  and  equal.  Heberden's  nodes 
were  well  marked.  Temperature,  pulse,  and  respiration  were  practi- 
cally normal  during  the  eight  weeks  of  her  stay  in  the  hospital,  except 
for  a  flare-up  in  the  last  of  February  following  injections  of  cacodylate 
of  iron.  The  data  concerning  the  blood  are  shown  in  Fig.  231.  Li  the 
stained  smear  the  red  cells  always  showed  a  large  amount  of  hemoglobin 
and  large  size,  with  an  occasional  stippled  or  off-color  cell.  Glycosuria 
was  present  for  the  first  month  of  her  stay,  the  output  of  sugar  averag- 
ing 10  gm.  per  day.'  There  was  no  acidosis  or  polyuria.  A  slight  trace 
.  of  albumin  was  usually  present,  with  a  few  hyaline  and  granular  casts. 

Discussion. — The  family  history  shows  strong  tendencies  to  arterio- 
sclerosis and  to  tuberculosis,  but  neither  of  these  diseases  can  be 
predicted  in  view  of  the  facts  indicated.  To  make  a  diagnosis  of 
mitral  regurgitation  would  be  the  ordinary  procedure  in  such  a  case, 
but  such  a  diagnosis  would  never  be  justified.  There  must  be  some- 
thing behind  it — the  "something"  of  which  the  regurgitation,  if  it 
exists,  is  symptomatic.  The  same  is  true  of  myocarditis,  the  tra- 
ditional term  on  which  we  often  fall  back  for  the  lack  of  any  better. 
I  cannot  see  that  the  case  fits  into  any  of  the  known  types  of  heart 
disease;  neither  am  I  content  to  call  it  merely  functional.  Probably 
the  state  of  the  blood  is  enough  to  account  for  everything.  The 
diagnosis  is  clearly  pernicious  anemia.  Without  a  blood  examination 
I  should  be  utterly  at  sea  in  such  a  case,  and  could  only  speculate 
and  investigate  regarding  the  possibility  of  alcoholism,  cocaine  habit, 
or  some  psychosis  in  the  background.  The  patient's  flushed,  flabby 
cheeks  and  the  absence  of  any  obvious  anemia  might  easily  mislead 
one  in  a  case  of  this  kind,  unless  a  blood  examination  were  a  matter  of 
cast-iron  routine  in  every  case. 

Outcome. — The  patient  felt  stronger  and  happier  in  the  middle  of 
February,  walked  about  a  little  each  day,  and  ate  fairly  well.  On  the 
loth  of  March  she  was  sent  to  the  Samaritan  Hospital. 


PALPITATION   AND   ARHYTHMLA  633 

Case  283 

A  Scotch  mill-worker  of  forty- two  entered  the  hospital  August  15, 
191 2.  About  a  year  ago  the  patient  noticed  that  her  heart  was  beating 
hard.  She  also  had  spells,  when  she  felt  as  if  "something  comes  over 
my  head,  darkness  across  my  eyes,  and  I  can't  go  out  into  the  open  air 
quick  enough."  These  symptoms  have  progressed  and  been  accom- 
panied by  shortness  of  breath  on  exertion,  resulting  finally  in  weakness 
so  marked  that  nine  months  ago  she  took  to  bed  for  six  months.  Three 
months  ago  she  felt  better  and  has  been  about  since.  Has  noticed  no 
increased  sweating,  but  has  been  growing  very  nervous  for  nearly  a 
year. 

On  physical  examination  the  heart's  dulness  extended  9  cm.  to  the 
left  of  midsternum  and  4  cm.  to  the  right.  Apex  impulse  felt  in  the 
fourth  space  corresponding  with  the  dulness.  The  sounds  were  rapid, 
irregular,  and  nearly  one-third  of  the  beats  do  not  reach  the  wrist. 
There  were  no  murmurs.  Blood-pressure,  120  mm.  Hg.,  systoHc; 
72  mm.  Hg.,  diastolic.  There  was  no  exophthalmos  and  no  goiter,  but 
the  fingers  showed  a  fine  tremor  when  extended.  Pupils  and  reflexes 
were  negative  and  there  was  no  edema.  Abdomen  and  lungs  negative. 
The  urine  averaged  60  ounces  in  twenty-four  hours,  with  a  specific 
gravity  of  loio,  no  albumin  or  casts.  White  corpuscles,  8000,  with 
47  per  cent,  polynuclears,  and  the  remainder  lymphocytes.  Her  past 
history  and  family  history  showed  nothing  of  importance. 

Under  rest  and  neutral  bromid  of  quinin,  5  gr.,  three  times  a  day, 
the  pulse  rapidly  improved,  and  by  the  21st  all  the  beats  reached  the 
wrist.  The  rhythm  at  that  time  suggested  the  fetal  type.  It  later 
appeared  that  she  had  been  given  a  good  deal  of  thyroid  extract  and  it 
was  suspected  that  her  symptoms  might  be  due  to  that  cause.  Her 
husband  deserted  her  several  years  ago,  and  she  has  been  much  tired 
and  worried  since.  She  left  the  hospital  much  improved  on  the  4th  of 
September. 

Discussion. — Here  is  a  middle-aged .  woman  with  absolute  arhyth- 
mia  and  tachycardia,  with  fine  tremor  of  the  fingers,  but  no  other 
evidences  of  Graves'  disease.  Obviously,  worry  and  fatigue  have 
something  to  do  with  her  condition,  but  it  is  not  likely  that  they 
account  for  the  whole  of  it.  The  condition  of  the  heart  does  not 
suggest  a  rheumatic,  syphilitic,  arteriosclerotic,  or  renal  t}T3e  of  heart 
disease.  Probably  the  administration  of  thyroid  extract  may  have 
contributed  to  produce  her  symptoms.  But  it  does  not  seem  to  me 
likely  that  this  is  sufficient  explanation.     In  a  normal  person  the 


634  DIFFERENTIAL  DIAGNOSIS 

amount  of  thyroid  extract  which  she  could  have  taken  without  entirely 
prostrating  herself  would  not  be  apt  to  produce  such  marked  symp- 
toms. I  believe  there  is  something  else  m  the  background — namely, 
thyrotoxicosis. 

Outcome.^September  24th  she  reported  at  the  Out-patient  De- 
partment feeling  pretty  well,  weighing  123!  pounds,  but  with  a  pulse 
of  128.  After  she  had  sat  still  for  half  an  hour  the  pulse  was  90. 
She  is  less  nervous,  but  still  trembles  at  times.  The  largest  circum- 
ference of  the  neck  was  35^  cm.  The  heart's  apex  was  in  the  fifth 
space,  just  outside  the  nipple  line.  Its  action  was  rapid  and  the 
sounds  of  tick-tack  quality.  October  8th  the  neck  measured  34  cm. ; 
there  was  considerable  tremor  of  the  hands;  the  pulse  was  96.  No- 
vember 29th  she  weighed  131  pounds,  the  neck  was  34I  cm.,  and 
the  pulse  114. 

A  letter  received  from  the  patient  December  11,  191 2,  says  there 
is  now  a  lump  in  the  front  of  her  neck  above  the  breast-bone.  In 
other  respects  she  is  improving  in  health. 

Case  284 

A  Russian  rag-picker  of  twenty-nine  entered  the  hospital  March  21, 
1910,  for  palpitation,  with  indefinite  pain  in  the  region  of  the  left 
m'pple  and  in  the  lower  back.  His  family  history  and  past  history 
were  not  remarkable.  He  smokes  from  25  to  60  cigarettes  a  day.  He 
has  no  dyspnea,  cough,  or  palpitation,  but  feels  weak  and  tight  across 
his  chest.  These  sensations  ire  not  increased  by  exertion  or  by  food, 
but  are  worse  when  he  has  headaches  or  when  doctors  are  about 
him.  They  are  sometimes  associated  with  dizzy  spells.  He  has 
worked  steadily  and  has  lost  no  weight. 

Physical  examination  shows  a  marked  tremor  of  the  eyelids  and 
an  old  puckered  white  scar  under  the  ramus  of  the  left  jaw.  The 
cardiac  apex  extends  2  cm.  outside  the  nipple,  as  estimated  by  sight 
and  touch.  The  right  border  extends  5  cm.  from  the  midsternal  line. 
Between  the  first  and  the  second  sound  of  every  alternate  cardiac 
cycle  two  faint  short  sounds  are  interposed.  In  this  cycle  there  is 
no  murmur,  but  in  the  normal  alternate  cycle  a  systolic  murmur  is 
heard  about  the  region  of  the  apex-beat.  Blood-pressure  normal. 
The  pulses  are  equal,  and  the  extra  beat  heard  at  the  apex  rarely 
reaches  the  wrist,  so  that  the  rhythm  is  usually  regular  there.  In 
other  respects  physical  examination,  including  the  urine,  is  negative. 
Venous  tracings  showed  this  beat  to  be  an  auricular  extrasystole. 
The  patient's  cardiac  condition   causes  him  actually  no  symptoms, 


PALPITATION   AND   ARHYTHMIA  635 

and  the  close  observation  seemed  to  be  tending  to  make  him  neu- 
rasthenic.    He  was,  accordingly,  sent  home  on  the  24th. 

Discussion. — This  case  represents  the  best  that  I  have  been  able 
to  do  to  find  a  marked  heart  trouble  attributed  to  tobacco,  and  I  do 
not  feel  at  all  sure  that  the  tobacco  is  the  main  cause  of  his  troubles, 
for  when  the  drug  was  taken  away  from  him  his  cardiac  condition 
was  not  much  different  from  that  which  troubled  him  at  the  beginning. 
Presumably,  the  heart  has  been  treated  by  the  administration  of  digi- 
talis. The  alternation  of  strong  and  weak  beats  is  what  we  expect 
to  see  under  these  conditions.  We  have  no  evidence  of  organic  dis- 
ease in  the  heart  beyond  a  certain  amount  of  enlargement;  possibly 
a  neurasthenia  accounts  for  the  whole  thing.  The  lack  of  any  in- 
crease in  his  symptoms  after  exertion,  and  their  aggravation  by  close 
observation,  seem  to  indicate  that  nervous  causes  are  the  most  im- 
portant part  of  his  trouble.  Such  a  patient  should  be  told  to  keep 
clear  of  doctors  and  go  about  his  business;  if  he  has  any  organic  disease, 
he  is  not  likely  to  mind  the  advice  long.  If  he  has  not,  it  will  do  him 
good,  more  good  than  anything  else  that  we  can  do. 

Case  285 

A  clerk  of  nineteen  entered  the  hospital  April  ii,  1910.  The 
patient's  family  history  was  excellent.  With  ordinary  colds  he  has 
often  had  asthmatic  attacks,  and,  although  he  has  played  football 
without  difficulty,  he  believes  that  his  heart  has  always  been  weak. 
He  uses  no  tobacco  or  alcohol,  and  takes  only  one  cup  of  tea  and  one 
cup  of  coffee  daily.  About  the  ist  of  February,  1910,  he  began  to 
have  attacks  of  palpitation  with  sharp,  needle-like  pains  in  the  pre- 
cordia,  coming  fifteen  to  twenty  times  a  day  and  lasting  ten  to  twelve 
minutes,  not  influenced  by  food  or  by  exertion.  There  has  been  no 
dyspnea,  palpitation,  cough,  or  other  symptoms,  except  loss  of  strength, 
which  has  been  noticed  for  about  four  months. 

Physical  examination  showed  good  nutrition,  negative  pupils 
and  reflexes.  The  heart's  apex  seen  and  felt  in  the  fifth  space,  1 1|  cm. 
from  midsternum,  2  cm.  outside  the  nipple  line,  the  right  border  i^  cm. 
from  midsternum.  The  heart's  action  was  irregular.  During  five 
minutes  of  auscultation  the  heart  would  be  regular  for  thirty  to  forty 
beats,  then  would  follow  a  succession  of  rapid  strokes,  irregular,  both 
in  force  and  frequency,  the  first  sound  apparently  reduplicated  at 
times.  No  murmurs  were  heard.  Pulmonic  second  sound  seemed  to 
be  accentuated.  The  pulses  and  radials  were  not  abnormal,  and 
visceral  examination,  including  urine,  was  otherwise  negative.    Blood- 


636  DIFFERENTIAL  DIAGNOSIS 

pressure  normal.  The  blood  showed  a  slight  achromia  and  a  poly- 
nuclear  leukocytosis  of  15,000.  Venous  tracings  showed  no  defect 
in  conduction.  After  exercise  the  heart  was  always  much  more 
regular  than  when  he  was  sitting  still.  The  Wassermann  reaction 
was  negative,  and  nothing  further  of  interest  was  observed  during 
ten  days  of  his  stay  in  the  hospital.  At  times  the  radial  pulse  and 
the  aortic  second  sound  would  be  quite  regular,  even  when  the  apex 
sounds  seemed  to  be  decidedly  mixed  up,  owing  to  doubling  of  the 
first  or  the  second.  The  precordial  pain,  of  which  'he  complained  at 
entrance,  was  not  relieved. 

Discussion. — All  the  signs  in  this  case  seem  to  me  to  point  toward 
a  neurotic  type  of  prostration.  Of  special  importance  is  the  fact  that 
his  heart  is  more  regular  after  exercise  than  on  sitting  still.  This  is  a 
test  of  great  value  and  should  always  be  applied  in  doubtful  cases. 

Although  he  states  that  his  heart  has  always  been  weak,  he  seems 
to  have  had  no  functional  difficulties,  and  one  can  place  but  Httle 
importance  upon  his  statement,  since  he  has  played  football  without 
difficulty. 

The  needle-Hke  precordial  pains  accompanying  his  palpitation 
are  such  as  we  have  all  frequently  seen  in  cardiac  neuroses;  often 
they  seem  to  be  connected  with  gastric  flatulency.  The  doubling  of 
heart  sounds  which  the  record  shows  is  probably  of  no  importance  in 
an  otherwise  healthy  boy  of  this  age. 

Perhaps  it  is  incorrect  to  call  him  sound,  since  his  heart's  apex 
is  somewhat  outside  the  nipple  line.  Without  any  a:-ray  control  of 
this,  however,  I  should  not  consider  it  of  much  significance.  The 
type  of  arhythmia  is  probably  respiratory,  a  so-called  sinus  arhyth- 
mia. 

Outcome. — December  22,  1912,  the  patient's  physician  writes 
that  he  has  been  at  work  steadily  except  for  the  first  month  after  he 
left  the  hospital,  that  he  has  not  lost  a  single  day  since  then,  and 
appears  to  be  in  very  good  health. 

Case     286 

An  engineer  of  thirty- three  entered  the  hospital  February  5,  191 2. 
The  patient's  family  history  is  excellent  and  past  history  not  remark- 
able. Eight  years  ago,  while  working  in  a  chair  factory,  he  noticed 
very  profuse  sweating  on  slight  provocation,  and  at  the  same  time 
he  lost  much  weight.  After  two  months  he  saw  a  doctor,  who  said 
that  he  had  "enlargement  of  the  heart  and  trouble  in  the  gland." 
After  a  vacation  he  felt  much  better  and  returned  to  work,  where  he 


PALPITATION   AND   ARHYTHMIA 


637 


felt  well  enough  for  five  years.  Three  years  ago  he  began  again  to 
lose  weight  and  his  neck  became  swollen.  The  local  physician  at 
that  time  thought  his  condition  serious  and  made  him  give  up  work. 
He  then  stayed  upon  a  farm  for  a  year  and  a  half,  during  which  time 
he  improved  much  and  noted  considerable  reduction  in  the  size  of  his 
neck.  For  the  past  year  and  a  half  he  has  been  working  hard  as  an 
engineer  and  has  felt  fairly  well  until  six  months  ago,  when  his  neck 
again  began  to  swell  intermittently.  Profuse  sweating  also  returned, 
and  his  pulse  has  been  very  rapid.  He  has  noticed  no  prominence 
of  the  eyes. 

On  physical  examination  the  heart's  apex  extended  i^  cm.  to  the 
left  of  the  nipple,  in  the  fifth  space.     The  sounds  were  clear,  between 


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100  and  no,  but  there  was  a  systolic  murmur  and  presystolic  thrill 
at  the  apex.  The  thyroid  gland  was  moderately  enlarged  on  each 
side,  and  there  was  slight  exophthalmos,  slight  tremor,  and  consider- 
able moisture  of  the  hands.  Physical  examination,  including  the 
urine,  was  otherwise  negative.  The  patient  was  seen  in  consulta- 
tion by  Dr.  F.  C.  Shattuck,  who  diagnosed  a  long-standing,  well-com- 
pensated mitral  stenosis,  and  was  doubtful  as  to  whether  hyper- 
thyroidism played  any  part.  He  thought  the  heart  needed  no  treat- 
ment, but  advised  regulation  of  hygiene.  As  the  patient  had  a  hernia, 
a  radical  operation  for  this  lesion  and  an  appendectomy  were  done. 


638  DIFFERENTIAL  DIAGNOSIS 

The  appendix  showed  scar  tissue  with  obliteration  of  the  lumen.  It 
was  adherent  to  the  hernial  sac  and  formed  a  part  of  it.  The  whole 
operation  was  done  under  local  anesthesia  and  caused  at  the  time 
no  considerable  shock.  About  six  hours  later  the  patient  vomited 
and  the  pulse  began  to  rise,  so  that  next  day  it  reached  140.  No 
cause  for  temperature  was  found,  but  the  amount  of  exophthalmos 
was  slightly  increased  for  about  a  week  after  the  operation.  On  the 
5th  of  February  he  was  transferred  to  the  medical  service,  where  his 
systoKc  blood-pressure  was  found  to  be  160  mm.  Hg.;  diastoHc,  85 
mm.  Hg.  (Fig.  232). 

Despite  careful  questioning,  no  evidence  of  any  cause  for  endo- 
carditis could  be  found,  and  it  was  learned  that  palpitation  on  exer- 
tion and  emotion  had  been  noticed  for  at  least  twelve  years.  The 
palpitation  has  at  times  been  so  great  as  to  shake  his  bed  at  night, 
and  was  accompanied  by  great  nervousness  and  sweating.  At  no 
time  has  he  had  any  edema  or  cough.  An  occasional  short  presystoKc 
roll  was  at  this  time  heard.  The  apex  was  2  cm.  outside  the  nipple 
line,  in  the  fifth  space.  The  aortic  second  greater  than  the  pulmonic 
second.  Pulse  tracings  showed  an  absolute  arhythmia,  but  no  evi- 
dence of  tricuspid  insufficiency.  This  arhythmia  persisted  after 
atropin,  subcutaneously,  j^-^  gr.,  repeated  in  six  hours.  He  had  occa- 
sional spells  of  tachycardia,  in  which  the  heart's  rate  would  rise  to  130 
to  160. 

Discussion. — I  should  not  have  inserted  this  case  but  for  tne 
fact  that  a  distinguished  clinician  differed  strongly  from  the  diagnosis 
of  goiter  heart  or  thyrotoxicosis,  which  seemed  to  me  clearly  war- 
ranted by  the  facts.  I  have  never  seen  a  case  of  pure  mitral  stenosis 
in  a  man  of  thirty-three  which  produced  a  systoKc  blood-pressure  of 
160  mm.  Hg.  The  presence  of  goiter  tumor,  unusual  sweating,  and 
slight  exophthalmos  seem  to  me  to  leave  no  considerable  doubt  as 
to  the  diagnosis.  Whether  or  not  he  had  mitral  stenosis  in  addition 
to  thyrotoxicosis  I  do  not  know.  I  am  convinced  that  a  presystolic 
murmur  may  exist  in  any  type  of  enlarged  heart,  and  not  merely 
with  aortic  regurgitation,  as  described  by  Flint.  That  the  murmur 
disappeared  when  the  heart  was  slow  does  not  furnish  evidence  either 
for  or  against  mitral  stenosis.  Neither  does  the  existence  of  absolute 
arhythmia  exclude  thyroid  disease. 

Outcome. — When  the  heart  was  slow  no  presystolic  roll  could  be 
heard,  and  on  the  24th  of  February  he  was  discharged.  A  year  later 
the  patient  reported  that  he  still  had  tachycardia,  but  had  been  work- 
ing-steadily  and  holding  his  weight  since  June  i,  191 2. 


CHAPTER  XVIII 

TREMOR 

Tremors  are  classified  as  coarse  and  fine,  the  latter  particularly 
characteristic  of  thyrotoxicosis.  Coarse  tremors  are  common  to  a 
great  many  states  presently  to  be  mentioned. 

The  commonest  of  all  causes  for  tremor  are  cold,  nervousness ,  and 
fatigue.  After  hard  muscular  work  the  hand  shakes.  In  difficult 
situations  the  knees  knock  together.  The  only  importance  of  such 
types  is  that  we  should  take  sufficient  pains  to  exclude  them  when 
considering  diseases  in  which  tremor  forms  an  essential  element. 
One  does  not  want  to  condemn  a  person  as  alcoholic  or  burdened  with 
thyroid  disease  merely  because  the  hand  shakes  from  apprehension  oV 
tire.  One  must  be  sure  that  the  psychic  conditions  are  understood 
and  that  we  are  getting  a  fair  sample  of  the  patient's  muscular  condi- 
tion. 

In  old  age  there  is  a  tremor,  especially  of  the  head,  which  does  not 
connect  itself  with  any  known  pathology  and  must  be  distinguished 
from  the  much  more  serious  conditions  of  the  nervous  system  to  be 
mentioned  below.  The  diagnosis  of  senile  tremor  depends  on  the  ex- 
clusion of  all  causes  except  senility  and  the  absence  of  the  associated 
S5nnptoms  of  paralysis  agitans.  It  is  often  seen  in  arteriosclerosis,  but 
there  is  no  proof  of  an  etiologic  connection. 

The  tremor  of  alcoholism  is  coarse  and  irregular.  It  appears  espe- 
cially in  the  morning  hours,  when  alcohol  is  suddenly  taken  away  or 
when  the  person  is  sobering  up ;  in  other  words,  under  the  same  condi- 
tions which  produce  alcoholic  delirium  or  the  trembling  dehrium 
(delirium  tremens).  It  sometimes  has  the  characteristics  of  an  inten- 
tion tremor,  but  can  be  controlled  to  some  extent  by  the  will. 

In  Graves^  disease  {thyrotoxicosis)  the  tremor  is  more  rapid  and  of 
shorter  excursion  than  in  any  other  condition  that  I  know.  It  is 
often  to  be  recognized  only  when  the  fingers  are  extended  and  spread 
apart.  It  is  present  constantly,  although  it  may  be  accentuated  by 
temporary  causes  of  nervousness.  It  is  seldom  bad  enough  to  inter- 
fere with  the  ordinary  use  of  the  hands.  It  may  be  an  early  or  a  late 
symptom  of  the  disease,  but  should  always  be  looked  for  in  doubtful 
cases. 

639 


640  DIFFERENTIAL   DIAGNOSIS 

Parkinson^ s  disease,  or  paralysis  agilajis,  is  the  next  most  common 
cause  of  tremor.  It  usually  appears  first  in  the  hands  and  produces 
peculiar  movements  of  the  thumb  and  first  two  fingers,  which  have  been 
compared  to  pill  rolling  or  bread  crumbling.  It  is  a  relatively  slow  and 
coarse  tremor,  and  although  it  begins  in  the  hand,  may  spread  up- 
ward, in  the  course  of  time,  to  involve  the  arms,  head,  and  even  the 
legs.  It  is  increased  by  excitement,  but  can  generally  be  lessened  by 
voluntary  effort.  Its  diagnosis  depends  upon  the  presence  of  the 
associated  symptoms  of  the  disease,  especially  the  muscular  rigidity, 
the  bent  and  rigid  carriage,  the  mask-like,  expressionless  face,  and  gen- 
eral muscular  weakness. 

Lead-poisoning  occasionally  produces  tremor,  in  connection  with 
other  evidences  of  neuritis.  The  same  is  true  of  mercurial-poisoning 
and  of  most  of  the  drug  habits,  such  as  morphinism,  cocainism,  etc. 

In  multiple  sclerosis  and  other  cerebral,  as  well  as  spinal,  lesions 
we  have  an  intention  tremor,  that  is,  one  which  is  more  marked  when 
the  patient  tries  to  use  the  muscles  or  is  made  worse  by  voluntary  effort. 
In  multiple  sclerosis  such  a  tremor  is  often  associated  with  nystagmus 
and  disturbances  of  speech,  which  render  it  slow,  segmented,  or  stac- 
cato; also  a  spastic  type  of  paralysis.  The  disease  presents  a  great 
variety  of  types  depending  on  the  varying  distribution  of  the  lesions. 

Case  287 

A  choreman  of  fifty-three  entered  the  hospital  February  22,  19 10. 
The  patient's  family  history  is  negative.  He  had  "pleurisy  and 
pneumonia"  on  the  left  side  eight  years  ago.  He  takes  "two  glasses 
of  beer  a  day  and  an  occasional  whisky."  Four  weeks  ago  a  freight 
elevator  fell  on  him,  striking  his  head,  but  not  injuring  him  in  any  other 
way.  The  scalp  wound  healed  in  ten  days,  but  since  the  injury  he  has 
had  a  dull  pain  running  from  the  nape  of  the  neck  along  the  shoulders, 
intensified  by  any  sudden  movement  of  the  head.  The  appetite  has 
been  poor  for  a  long  time  and  he  has  not  worked  since  the  accident. 
His  sleep  has  been  very  poor. 

Physical  examination  showed  good  nutrition,  subnormal  tem- 
perature (Fig.  233),  and  a  marked  coarse  tremor  of  the  hands.  The 
heart's  apex  extended  i  cm.  outside  the  nipple.  The  pulmonic  sec- 
ond sound  was  accentuated.  There  were  no  murmurs.  The  brachial 
arteries  were  tortuous  and  pulsated  visibly.  Systolic  blood-pressure, 
165.  Urine  negative.  White  cells,  20,000,  with  a  polynuclear  leuko- 
cytosis; hemoglobin,  90  per  cent.  There  was  slight  dulness  and 
decreased  breathing  at  the  left  apex,  posteriorly.     Abdomen  showed 


Tremor 


SENILITY 

COLD 

NERVOUSNESS 

EXHAUSTION 

ALCOHOLISM 

EXOPHTHALMIC  GOITER 

MORPHINISM 

MULTIPLE  SCLEROSIS 

GENERAL  PARESIS 

PARKINSON'S  DISEASE 


CASES  TOO   MANY  AND   TOO  VAGUELY  ENUMERABLE    FOR    GRAPHIC   REP- 
RESENTATION 


830 

290 

100 

32 

26 

26 


Vol.  11—41 


641 


642 


DIFFERENTIAL  DIAGNOSIS 


nothing  abnormal.     The  night  after  entrance  he  became  belligerent 
and  thought  he  had  been  wronged  by  another  patient. 

Discussion.— ^The  fact  that  the  patient  has  not  worked  since  his 
accident  and  has  not  been  able  to  sleep  well  should  make  us  very  suspi- 
cious of  alcoholism,  no  matter  what  the  patient 
himself  says  on  the  subject.  Workingmen  of 
fifty-three  do  not  suddenly  acquire  insomnia 
from  the  ordinary  causes  affecting  nervous  and 
highly  civilized  people. 

The  behavior  of  the  patient  in  the  hospital, 
the  appearance  of  cerebral  symptoms  in  the 
evening,  gives  the  support  to  the  suspicion  of 
alcohoHsm,  and  makes  us  pretty  certain  that  he 
has  taken  a  good  deal  more  than  two  glasses  of 
beer  a  day  and  an  occasional  whisky. 

There  may  be  a  certain  element  of  traumatic 
neurosis  in  the  case.  In  such  conditions  tremor 
is  frequent,  but  it  is  more  probable  that  the  alco- 
holism is  the  dominant  factor. 

Obviously,  the  patient  has  some  arterioscle- 
rosis, but  this  has  probably  no  relation  to  the 
tremor. 

Outcome. — The  next  morning  he  was  appar- 


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Case  287. 

ently  rational.     X-ray  examination  of  his  neck  was  negative.   He  left 
the  hospital  on  the  28th,  after  a  negative  examination  by  an  alienist. 


Case  288 

A  housewife  of  fifty-one  entered  the  hospital  July  23,  19 10.  The 
patient  was  recommended  from  the  Out-patient  Department  for 
tremor,  edema  of  the  legs,  and  slight  chronic  arthritis.  Ten  years  ago 
she  was  in  bed  four  weeks  with  intense  jaundice,  but  no  pain.  During 
the  two  years  following  this  she  suffered  from  frequent  attacks  of  epi- 
gastric pain,  lasting  several  hours.  Five  years  ago  she  had  typhoid 
fever  and  was  in  bed  four  months.  She  passed  the  menopause  seven 
years  ago. 

Sixteen  months  ago  she  woke  too  weak  to  get  up,  and  remained 
ten  weeks  in  bed  with  what  the  doctor  called  "nervous  prostration." 
Since  that  time  she  has  been  about  the  house  daily,  but  has  suffered 
much  pain  in  both  hips.  During  the  last  few  months  her  hands  have 
trembled. 

The  pain  has  prevented  good  sleep,  and  she  has  taken  always  \ 


TREMOR 


643 


gr.  codein,  which  produces  about  two  hours'  sleep.     The  appetite  is 
fair.     The  bowels  move  every  other  day.     She  has  lost  no  weight. 

On  physical  examination,  the  patient  is  very  poorly  nourished  and 
sallow.  Pupils  normal.  Internal  viscera  normal.  Knee-jerks  and 
plantars  normal.  Achilles  reflexes  not  obtained.  Marked  Kernig's 
sign  bilateral.  The  neck  is  held  stiffly,  bent  markedly  forward  and  to 
the  right.  All  the  muscles  are  spastic.  The  hip-joints  are  sore  on 
motion,  the  knees  slightly  so.  There  is  well-marked 
intention  tremor  of  the  hands  and  considerable 
tremor  of  the  legs  when  attention  is  directed  to 
them.  The  back  is  stiff  and  shows  a  lateral  curv- 
ature, most  marked  in  the  lower  thoracic  region, 
with  a  convexity  to  the  left.  The  range  of  the 
temperature  is  shown  in  Fig.  234.  The  urine 
averaged  35  ounces  in  twenty-four  hours.  It  was 
always  turbid  and  acid,  with  a  specific  gravity  of 
1023.  Negative  sediment.  The  blood  was  nor- 
mal. Systolic  blood-pressure,  105.  The  patient 
went  home  on  the  28th. 

Discussion. — The  case  is  obviously  one  of  Par- 
kinson's disease,  and  is  here  introduced  to  call  at- 
tention to  the  fact  that  pain  and  other  joint  syinp- 
toms  may  be  very  prominent  in  the  clinical  picture 
of  paralysis  agitans.  At  the  time  of  this  patient's 
examination  in  the  hospital  there  was  actually  no 
tremor  at  all,  and  one  must  be  prepared  to  recog- 
nize the  disease  in  the  absence  of  this  symptom, 
paying  especial  attention  to  the  expression  of  the  face,  the  stiffness  of 
the  neck  and  back,  and  the  peculiarities  of  the  gait. 

Note  that  the  doctor  made  a  diagnosis  of  nervous  prostration  only 
sixteen  months  ago,  a  diagnosis  which,  of  course,  is  never  correct  when 
its  symptoms  originate  in  a  person  of  forty-nine. 


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of   Case  288. 


Case  289 

A  foreman  in  a  hay  and  grain  house,  forty-four  years  old,  entered 
the  hospital  July  28,  1910.  The  patient's  family  history  is  negative. 
Nineteen  years  ago  he  had  "sciatic  rheumatism"  for  three  weeks; 
otherwise  was  well  and  strong  until  the  present  illness.  March  i ,  1909, 
he  had  a  severe  sore  throat  with  a  peritonsillar  abscess.  Just  after 
this  he  ate  some  well-done  pork  at  a  restaurant.  Seven  hours  later  he 
felt  dopy.     Twenty  hours  later  he  noticed  a  rash  all  over  his  body. 


644  DIFFERENTIAL  DIAGNOSIS 

This  rash  lasted  ten  days  and  was  accompanied  by  a  tough  swelling 
of  the  skin,  suggesting  myxedema  to  his  physician.  He  desquamated 
in  large  pieces,  but  did  not  feel  sick,  and  March  15th  went  back  to  work. 
April  20th  he  began  to  feel  pain  and  tenderness  in  his  elbows  and  his 
groins,  and  his  doctor  found  tenderness  along  the  ulnar  side  of  each 
arm.  April  24th  his  hands  began  to  shake,  so  that  on  the  27th  he  had 
to  quit  work  and  has  not  been  able  to  resume  it  since. 

Gradually  numbness  crept  up  his  arms  until  they  were  paralyzed. 
Then  the  legs  became  powerless.  There  was  much  paresthesia,  but  no 
anesthesia  and  no  involvement  of  sphincters,  speech,  or  swallowing. 
The  power  has  gradually  returned  in  his  arms  and  partially  in  his  legs, 
but  he  cannot  straighten  his  knees. 

In  other  respects  his  health  is  good,  but  he  has  lost  about  20  pounds. 
He  knows  of  no  exposure  to  lead. 

Physical  examination  showed  a  rather  obese  patient,  with  normal 
pupils,  and  nothing  remarkable  about  his  internal  viscera.  Knee- 
jerks,  ankle-jerks,  and  plantars  were  absent.  Cremasterics  present  on 
both  sides.  Abdominal  reflexes  not  obtained.  There  was  practically 
no  motion  below  the  knees  and  a  moderate  contraction  of  the  hamstring 
muscle.  No  toe-drop.  Motions  of  the  left  hand  were  fair,  but  rather 
weak.  The  little  finger  moderately  contracted.  The  right  hand  was 
moderately  abducted  from  the  forearm  and  the  fingers  were  in  the 
position  of  a  typical  claw-hand.  The  grasp  was  weak,  and  there  was 
considerable  atrophy  in  this  and  in  the  other  hand,  especially  at  the 
base  of  the  thumb.  Sensation  of  touch  was  delayed  and  inaccurate 
in  the  feet,  fair  in  the  legs  and  hands,  good  in  the  rest  of  the  body. 
The  extensor  muscles  of  the  arms  and  hands  reacted  to  galvanism,  but 
a  strong  faradic  current  was  necessary  to  produce  any  reaction.  All 
electric  reactions  were  absent  in  the  perineal  muscles.  The  Wasser- 
mann  reaction  was  positive. 

The  patient  was  given  Zander  exercises,  electric-light  baths,  and 
massage,  and  by  August  6th  could  stand  on  his  feet.  August  13th  he 
could  take  a  few  steps  with  help.  An  orthopedic  consultant  advised 
tenotomy  of  the  hamstrings,  but  under  Zander  treatment  his  legs  were 
considerably  straightened  by  the  30th.  By  September  7th  the  patient 
had  shown  very  marked  improvement  and  was  transferred  to  the 
neurologic  wards,  where  a  slight  edema,  duskiness,  and  coolness  of  the 
feet  were  found. 

Discussion. — In  view  of  the  positive  Wassermann  reaction  in  this 
case,  it  seems  to  me  that  the  diagnosis  of  peripheral  neuritis,  made  at 
the  time  of  his  stay  in  the  hospital,  is  a  very  doubtful  one.     It  must  be 


TREMOR  645 

admitted  that  the  physical  signs  and  condition  of  the  reflexes  support 
the  diagnosis  of  a  neuritis,  but,  in  the  absence  of  any  of  the  known 
causes  of  such  a  lesion  and  the  presence  of  a  Wassermann  reaction,  it 
seems  to  me  doubtful  whether  the  disease  is  confined  to  the  peripheral 
nerves. 

At  the  beginning  of  the  illness  there  were  some  etiologic  suggestions 
which  deserve  a  moment's  comment.  Peritonsillar  abscess  is  a  cause 
of  many  other  manifestations  of  infection  and  toxemia,  but  I  know  of 
no  good  evidence  for  connecting  it  with  nervous  symptoms  of  this 
type.  The  same  may  be  said  of  his  initial  rash  and  dull  mental  state 
following  the  eating  of  pork.  What  this  illness  was  I  have  no  idea. 
It  surely  cannot  have  been  beriberi  or  myxedema. 

On  the  whole,  I  must  admit  that  the  condition  is  by  no  means  a 
clear  one,  though  I  incline  to  the  opinion  that  syphilis  is  at  the  bottom 
of  it. 

Outcome. — September  26th  he  was  able  to  walk  alone  and  had 
moderate  strength  in  his  left  hand.  December  2,  191 2,  the  patient's 
physician  writes  that  he  can  now  walk  without  cane  or  crutches,  though 
he  still  has  toe-drop  and  some  deformity  and  weakness  in  the  hands. 

Case  290 

A  chair-caner  of  seventeen  entered  the  hospital  December  6,  1910. 
The  patient  came  in  because  of  a  twitching  of  the  left  arm.  While 
waiting  in  the  anteroom  for  examination  she  was  heard  screaming  and 
was  brought  in  in  the  arms  of  the  nurse,  apparently  comatose,  with 
face  bluish,  foam  on  the  Kps,  and  irregular  jerking  motions  of  the  arms 
and  legs.     The  pupils  and  knee-jerks  responded  normally. 

She  remained  unconscious  about  fifteen  minutes,  though  opening 
her  eyes  occasionally  without  looking  round.  The  subcutaneous  in- 
jection of  oV-gr.  apomorphin  caused  slight  nausea  and  a  renewal  of 
consciousness. 

The  patient  says  that  she  has  had  similar  attacks  at  irregular  inter- 
vals for  the  last  four  years,  though  sometimes  she  has  gone  a  year  with- 
out any,  and  again  she  would  have  them  every  week  or  two.  They  last 
fifteen  or  twenty  minutes,  begin  with  vertigo,  then  headache,  then  loss 
of  consciousness.  After  such  an  attack  she  has  to  lie  down  for  an  hour 
or  more  and  feels  very  weak.  A  year  ago  last  November  she  had  an 
attack  on  an  electric  car,  and  stayed  a  week  in  the  City  Hospital  there- 
after. 

Two  weeks  ago  blood  was  taken  from  her  left  arm  for  examination. 
The  next  morning  the  arm  was  twitching  when  she  aw^akened,  and  ever 


646  DIFFERENTIAL  DIAGNOSIS 

since  then,  as  she  sits  in  a  chair,  the  left  arm  and  shoulder  are  agitated 
by  a  constant  tremor,  which  sUghtly  shakes  the  whole  body,  while  the 
left  shoulder  is  draw^n  down.     There  is  a  sHght  limp  in  the  left  foot. 

Physical  examination  shows  well-marked  left  hemianesthesia.  The 
tremor  involves  chiefly  the  latissimus  dorsi.  The  anesthesia  is  not 
marked  upon  the  trunk  or  face,  but  is  most  striking  in  the  foot  and  arm. 
The  grip  of  the  left  hand  is  very  feeble.  Both  knee-jerks  are  exag- 
gerated, the  left  more  than  the  right.  No  plantar  reflexes  obtained 
upon  the  left.     The  left  ankle-jerk  is  exaggerated. 

No  notes  of  treatment  were  made  during  the  five  weeks  of  the 
patient's  stay  in  the  hospital,  during  which  she  passed  through  an 
attack  of  acute  tonsilUtis  and  two  menstrual  periods.  The  bowels 
were  decidedly  constipated,  several  days  often  passmg  without  any 
movement. 

Discussion. — The  initial  attack,  as  described,  might  be  either 
hysteric  or  epileptic,  although  the  fact  that  she  opened  her  eyes 
occasionally  and  that  apomorphin  brought  her  to  consciousness 
are  items  strongly  in  favor  of  hysteria. 

It  is  easier  to  interpret  the  attack  when  we  study  the  later  phases 
of  her  trouble  and  the  physical  examination.  Hemianesthesia  with 
exaggeration  of  both  knee-jerks  and  a  tremor  of  the  arm  following 
immediately  upon  the  extraction  of  blood  for  examination  makes  a 
clinical  picture  strongly  confirming  the  previous  suspicion  of  hysteria. 
Weir  Mitchell  has  described  similar  cases,  especially  one  classical  and 
spectacular  instance  in  which  later  a  careful  autopsy  showed  abso- 
lutely no  lesion — macroscopic  or  microscopic.^ 

Case  291 

A  man  with  no  occupation,  thirty-three  years  of  age,  entered  the 
hospital  June  29,  191 2.  The  patient's  family  history  is  excellent. 
He  had  the  ordinary  children's  diseases,  and  beginning  at  seven  years 
old  had  five  severe  attacks  of  rheumatic  fever,  the  last  one  four  years 
ago.  Since  that  time  he  has  noticed  palpitation  on  exertion  or  excite- 
ment, and  occasionally  shght  dyspnea.  He  denies  venereal  disease 
and  alcohol. 

Four  years  ago,  after  being  in  bed  three  months  with  rheumatic 
fever,  he  noticed  that  his  hands  trembled  and  made  uncertain  irregu- 
lar motions  when  he  used  them,  though  there  was  no  paralysis  or  dis- 
turbance of  sensation.  He  also  finds  himself  weak  and  unsteady  on 
his  feet  and  can  get  about  only  with  crutches.     Four  years  ago  his 

^  Transactions  of  the  Association  of  American  Physicians,  1904,  p.  433. 


TREMOR  647 

speech  was  very  thick  and  unintelligible.  He  knew  what  he  wanted 
to  say,  but  could  not  pronounce  the  words  correctly.  For  the  last 
two  years  he  has  been  training  himself  in  speech,  with  considerable 
improvement  as  a  result.  He  can  now  also  write,  paint,  and  do 
basket-work,  and  has  no  trouble  in  dressing  himself.  He  still  has  to 
use  crutches.  He  has  no  pain,  no  vertigo,  and  no  ocular  disturbance. 
For  a  short  time,  three  years  ago,  he  had  slight  incontinence  of  urine, 
but  that  soon  passed  off  and  has  not  recurred. 

Physical  examination  showed  good  nutrition,  slight  cyanosis, 
normal  pupils,  knee-jerks  equal  and  lively,  plantars  and  cremasterics 
normal.  Superficial  abdominal  reflexes  not  obtained.  All  motions 
of  the  trunk  and  arms  are  awkward  and  uncertain  and  accompanied 
by  a  coarse,  irregular  tremor,  not  fibrillary  in  character.  No  wasting. 
Grips  strong  and  equal.  Head  held  to  the  left,  mouth  slightly  drawn 
to  the  right.'  Tongue  protruded  slightly  to  the  right.  Speech 
slightly  thick,  but  not  scanning.  No  nystagmus.  The  fundus  oculi 
normal.  A  neurologic  consultant  was  in  doubt  between  hysteria 
and  multiple  sclerosis.  Wassermann  reaction  negative.  Blood  and 
urine  negative.  No  fever  in  ten  days'  observation.  Systolic  blood- 
pressure,  180  mm.  Hg.;  diastolic,  60  mm.  Hg.  By  lumbar  puncture 
a  few  cubic  centimeters  of  clear  fluid  were  obtained,  not  under 
pressure. 

The  cell-count  was  3  per  centimeter. 

The  heart's  apex  was  seen  and  felt  in  the  sixth  space,  5  cm.  out- 
side the  nipple  line.  There  is  a  slight  presystohc  thrill  at  this  point 
and  a  faint  presystohc  murmur,  ending  in  a  loud  first  sound  and  a  loud 
systolic  murmur.  At  the  aortic  area  and  along  the  left  sternal  border 
a  diastoUc  murmur  is  heard.  The  pulmonic  second  is  greater  than  the 
aortic  second,  which  is  very  faint. 

Pulses  markedly  Corrigan  in  quality.  Capillary  pulse  present. 
Lungs,  abdomen,  and  extremities  normal.  The  patient  remained  in 
the  hospital  ten  days  and  left  without  any  considerable  change  in  his 
condition. 

Discussion. — The  patient  has  all  the  evidences  of  rheumatic  or 
streptococcic  endocarditis,  with  mitral  stenosis  and  probably  aortic 
regurgitation  and  stenosis.  It  is  not  probable,  however,  that  the 
present  condition  of  the  hands  has  any  direct  connection  with  the 
rheumatic  infection.  We  note  that  the  ataxia  and  tremor  of  the 
hands  is  associated  with  disturbances  of  speech  and  of  gait.  The 
spasticity  often  seen  in  multiple  sclerosis  is  not  present. 

As  in  many  cases,  the  diagnosis  is  in  doubt  between  hysteria  and 


648  DIFFERENTIAL  DIAGNOSIS 

multiple  sclerosis.  Some  of  the  most  classical  and  disastrous  diag- 
nostic mistakes  that  I  have  known  have  been  those  in  which  the 
physician  called  the  case  hysteria  and  treated  it  accordingly,  when 
the  march  of  time  demonstrated  the  presence  of  an  incurable  organic 
disease,  multiple  sclerosis.  In  this  case  the  nature  and  duration 
of  the  trouble  with  speech,  the  transitory  attack  of  urinary  incon- 
tinence, the  muscular  abnormalities  in  the  head,  face,  and  tongue, 
incline  us  to  beUeve  that  organic  disease  is  present.  It  is  very  im- 
probable that  a  man  would  begin  to  be  hysteric  at  twenty-nine. 

Paresis  and  other  postsyphihtic  diseases  of  the  nervous  system 
may  be  excluded  by  the  negative  Wassermann  reaction  and  the  low 
cell-count  in  the  spinal  fluid. 

We  have  no  grounds  for  suspecting  multiple  neuritis.  Under 
these  conditions  the  diagnosis  of  multiple  sclerosis  seems  to  be  the 
most  defensible 


CHAPTER  XIX 

ASCITES  AND  ABDOMINAL  ENLARGEMENT 

I  RECENTLY  made  a  series  of  wrong  diagnoses  in  cases  of  ascites. 
These  failures,  which  were  shared  by  some  of  the  best  diagnosti- 
cians in  the  country,  suggested  to  me  a  study  of  the  causes  of  this 
symptom.  Until  recently  I  had  supposed  that  the  diagnosis  of  the 
causes  of  ascites  was  one  of  the  easiest  in  medicine.  I  was  amazed 
to  hear  Dr.  Rolleston  say,  in  1909,  that  he  considered  the  diagnosis 
of  cirrhosis  a  very  difficult  one;  but  in  the  light  of  recent  events  I 
have  come  to  agree  with  him.  To  minimize  the  number  of  future 
mistakes,  I  have  in  this  chapter  endeavored: 

1.  To  tabulate  from  the  autopsy  records  of  the  Massachusetts 
General  Hospital  the  actual  causes  of  ascites  as  found  postmortem 
in  2217  autopsies  (Chart  I). 

2.  To  tabulate  the  clinical  diagnoses  of  ascites  made  at  this 
hospital  in  the  last  forty  years.  Some  of  these  diagnoses  have  been 
verified  by  operation  or  autopsy.  A  larger  number  rest  on  clinical 
evidence  alone,  but  in  most  of  the  more  dubious  and  more  interesting 
cases  we  have  operative  or  postmortem  knowledge  of  the  actual 
condition  (Chart  II). 

3.  To  tabulate  the  rates  at  which  ascites  accumulates  in  different 
diseases.  Possibly  these  latter  facts  may  be  of  some  assistance  in 
identifying  through  its  more  or  less  characteristic  tempo  of  accumu- 
lation the  ascites  of  tuberculous  peritonitis  (Chart  V). 

4.  To  relate  some  of  my  failures  and  discuss  the  possibiUties  of 
better  success  in  the  future. 

Chart  I  shows  the  causes  of  fluid  as  found  in  the  peritoneum  in 
2217  cases  at  autopsy.  A  quart  or  more  of  fluid  was  present  in  all 
these  cases.  Cases  of  septic  peritonitis  and  hemoperitoneum  are 
omitted;  88  per  cent,  of  the  remaining  cases  are  due,  as  was  anti- 
cipated, to  one  of  five  causes:  Cardiac  weakness,  nephritis,  abdominal 
neoplasms,  cirrhotic  liver,  and  tuberculous  peritonitis. 

I  am  uncertain  whether  the  cases  of  adherent  pericardium  (all 
of  which  were  associated  with  extensive  peritoneal  thickening)  should 
be  classed  with  the  cases  of  cardiac  weakness  or  with  those  of  chronic 

649 


Causes    of    Ascites    as    Found    Postmortem    in 
2217  Autopsies 


ri 


CHRONIC     FIBROUS     PERI 
TONITIS 


ACUTE  YELLOW  ATROPHY) 
OF   LIVER  i 


CARDIAC  WEAKNESS  ■■^^^^■^■■■■■■■■■■IH  89  1 

NEOPLASMIC  PERITONITIS  ^^m^m^^^l  44 

RENAL   DISEASE  ^B^^i^  26 

CIRRHOSIS  OF  LIVER  ^mt^^M  23 

PERITONEAL  TUBERCULOSIS  ^^M  15  J 

ADHERENT  PERICARDIUM  ■■  9 

ECLAMPSIA  ■  3 
THROMBOSIS,  CAVAL,  MES 


197, 

or 
88% 


ENTERIC,  OR   PORTAl 

}- 

UTERINE  FiBROMYOMA  ■  3 

INTESTINAL  OBSTRUCTION      ■  2 

PANCREATITIS  I  1 

OVARIAN   CYST  I  1 


1 


STATUS   LYMPHATICUS  I  1 

TOTAL  224 

Chart  I. 


050 


Relative  Frequency  of  the  Common  Causes  of 

Ascites 


FROM     THE     CLINICAL     RECORDS     OF     THE      MASSACHUSETTS 
GENERAL   HOSPITAL,   1870-igio 


CARDIAC  WEAKNESS  ■■■^■^I^HHHHBHHI^^^HH  1397 

RENAL  DISEASE  HIHBaHH^HHH  665 

HEPATIC  CIRRHOSIS  ■^■^■i  325 

PERITONEAL  TUBERCULOSIS  ^m^tm  263 

INTESTINAL  OBSTRUCTION  HI  86 

OVARIAN  TUMORS  ■■  63 

INTESTINAL  CANCER'  ■§  56 

UTERINE  FIBROMYOMA  Bi  55 

PERITONEAL  CARCINOSIS  ■  53 

PERICARDIAL  ADHESIONS  ■  36 

HEPATIC  CANCErV/'  ■  30 

PERNICIOUS  ANEMIA  I  15 

LEUKEMIA  I  ''■' 

MESENTERIC  THROMBOSIS  I  8 

ABDOMINAL  LYMPHOMA  I  5 

VISCERAL  SYPHILIS^  I  * 

CAVAL  AND  PORTAL  I  2 

THROMBOSIS  >  I 


TOTAL  3074 


^  With  glandular  metastases. 
^  Hepatic,  splenic,  etc. 

Chart  II. 


651 


Percentage  of  Cases  of  Ascites  Found  in  5001 
Cardiac  Cases  Observed  Clinically 


MASSACHUSETTS  GENERAL   HOSPITAL,   1870-1910 


MITRAL    AND    TRICUSPID 
REGURGITATION 


AORTIC     STENOSIS    AND 
REGURGITATION 


MITRAL     STENOSIS     AND 
REGURGITATION 


MITRAL  AND  AORTIC  RE- 
GURGITATION 


652 


1 00% 


ADHERENT   PERICARDIUM       ■■■■^^^H^i^^HHI^I^Hi  76% 

MITRAL       AND        AORTIC]     

STENOSIS  AND    REGUR-  [     ■■^^■^■IHHB  42% 

CITATION  i 

"MYOCARDIAL  WEAKNESS"    I^BHIHH  37 


35 


AORTIC   REGURGITATION        ^IHHHIH  29 


24 


'MITRAL  REGURGTIATION"    ^^■■H  22 


20 


MITRAL  STENOSIS  ■■§  8 


Chart  III. 


Percentage  of  Ascites  Found  Among  10,195 
Cases  of  the  Diseases  Which  Produce  This 
Symptom  

MASSACHUSETTS   GENERAL   HOSPITAL,    1870-igio 


THROMBOSIS  (VENA  CAVA)       ■■■■■^^■■■^IHHI^Hai^^BH   100 
THROMBOSIS  (PORTAL)  gmg^^^^^^^^gg^^^m^mg^^   ^qq 


CIRRHOSIS  OF  THE  LIVER        ■■■■■^^^■la^Bll^^^a^^  88 

TUBERCULOUS  PERITONITIS    ^IH^^^^^HBBI^l^^^^^  82 


NEOPLASMIC  PERITONITIS        ■■■Hi^^^i^HBHHHBHHHl  82 

THROMBOSIS   (MESENTERY)     ■■■■■■^i^^^i^^^^^^^  80 

OVARIAN   FIBROMA  ^■■^i^i^H^HHII^^B  50 


MALIGNANT        LYMPHOMA 
(THORACIC  AND  ABDOM-  }■     ■^^^^^^^^^^■■B  50 


I  NAD 
INTESTINAL  OBSTRUCTION      ^^^^■■■■■^^^  43 


SYPHILIS    OF    THE    LIVER, 
ETC. 


CARDIAC    WEAKNESS,    ALL\ 
CAUSES  i 


CANCER       OF       PANCREAS  1 
AND  LYMPHATIC  GLANDS  » 

CANCER     OF     LIVER     AND| 
LYMPHATIC  GLANDS  i 


OVARIAN      CYST,      MULTI- 
LOCULAR 


40 


OVARIAN  CANCER  ■■■■■■■l^^^^  39 


RENAL  AND  CARDIORENAL       i^^^l^^HHHBi  29 

CANCER      OF      INTESTINES      ^^^^^^^ 
AND  LYMPHATIC  glands/     ^^^^^^^^ 


22 


20 


OVARIAN  SARCOMA  HHI^^^HB  20 

LEUKEMIA  i^^^H  13 


PERNICIOUS  ANEMIA  IBB  7 


UTERINE  FIBROMA  ■■  7 

Chart  IV. 

6S3 


654  DIFFERENTIAL   DIAGNOSIS 

peritonitis.     Of  the  other  items  in  the  list,  the  one  most  surprising 
to  me  is  puerperal  eclampsia. 

CLINICAL  STATISTICS  OF  ASCITES 

In  some  of  the  cases  arranged  in  Chart  II  the  diagnosis  was  veri- 
fied by  operation  or  autopsy.  This  was  the  case  with  all  the  neo- 
plasms and  thromboses,  and  with  most  of  the  cases  of  intestinal 
obstruction  and  tuberculous  peritonitis;  but  in  the  cardiac,  renal, 
and  hepatic  cases,  and  most  of  the  blood  diseases,  the  evidence  is 
wholly  clinical. 

Points  of  interest  in  this  column  are :  (a)  The  frequency  of  ascites 
with  ovarian  cysts  and  tumors  (see  below,  Chart  VI),  and  (b)  the 
large  figures  obtained  in  intestinal  obstruction.  Probably  in  a  con- 
siderable number  of  these  cases  the  fluid  may  have  been  due  to  actual 
peritonitis  associated  with  the  obstruction. 

In  this  chart  all  the  unstarred  items  represent  cases  actually 
studied  in  the  original  clinical  record.  The  items  which  are  starred 
were  calculated  as  follows: 

Throughout  an  eight  year  period  I  determined,  by  study  of  the 
clinical  records,  the  percentage  of  ascitic  cases  among  all  the  cases 
of  cardiac  and  renal  disease.  These  positive  percentages  were  then 
applied  to  the  total  number  of  cases  of  each  disease,  as  shown  by  a 
count  of  the  cards  in  the  card  catalogue  (1870-1910).  The  starred 
items  are,  therefore,  only  approximately  accurate. 

Chart  V 

Rate  of  ascitic 

No.  of  accumulation. 

Disease.                                                         cases.  Ounces  per  day. 

1.  Cardiac  weakness 2  3^-54 

2.  Cirrhosis  of  the  liver 16  20 

3.  Chronic  nephritis 5  13 

4.  Solid  tumors  of  ovary 2  12 

5.  Neoplasms  of  the  abdominal  organs  and  glands     4  11 

6.  Adherent  pericardium  (before  cardiolysis) 2  11 

Adherent  pericardium  (after  cardiolysis) i  2 

7.  Uterine  fibroid 2  8-11 

8.  Tuberculous  peritonitis 15  S~  6 

Chart  V  requires  little  explanation.  The  number  of  ounces  of 
fluid  between  two  exhaustive  tappings  is  divided  by  the  number  of 
days  intervening.  There  is  a  chance  for  error  here,  in  that  the  tappings, 
which  were  supposed  to  empty  the  peritoneal  cavity,  may,  in  fact, 
have  left  some  fluid  behind;  but  I  do  not  think  that  this  error  is 
sufl&ciently  serious  to  interfere  with  my  results. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  655 

ASCITES  WITH  SOLID  TUMORS  OF  THE  OVARY 

1.  Cancer  of  the  Ovary. — Fifty-four  cases  are  on  record  at  the 
Massachusetts  General  Hospital  between  1870  and  1910.  In  6  of 
these  there  was  no  operation  or  autopsy.  Of  the  remaining  48,  there 
were  19  cases  (40  per  cent.)  in  which  a  considerable  amount  of  ascites 
was  found. 

2.  Fibroma  of  the^  Ovary. — Twenty  well-recorded  cases  are  to  be 
found  in  our  records.  In  10  of  these  (50  per  cent.)  ascites  was  well 
marked  at  the  time  of  operation. 

3.  Sarcoma  of  the  Ovary. — Five  cases,  i  with  ascites. 

ASCITES  WITH  CYSTIC  TUMORS  OF  THE  OVARY 
There  were  391  cases  operated  upon  at  the  Massachusetts  General 
Hospital  (1870-1910)  for  multilocular  ovarian  cyst.  In  31  of  these 
(7.9  per  cent.)  ascites  was  well  marked  at  the  time  of  operation. 
In  8  of  these  31  the  fluid  was  bloody  or  chocolate  colored.  In  i  the 
amount  of  serum  was  measu'red  at  17  quarts. 

ASCITES  WITH  UTERINE  HBROMYOMA 

Among  723  cases  operated  upon  for  fibroid  of  the  uterus,  55 
cases  (7  per  cent.)  showed  ascites.  This  was  of  small  amount  in 
18  cases  (2.4  per  cent.);  of  large  amount  in  the  remaining  37  (4.6 
per  cent.). 

In  10  of  the  55  cases  the  fluid  was  bloody,  in  2  others  it  was  purulent. 

In  Chart  VI  the  relation  of  ascites  to  the  different  varieties  of 
ovarian  tumor  is  demonstrated.  All  these  cases  were  operated  on. 
I  think  many  persons  will  be  surprised,  as  I  was,  to  learn  how  fre- 
quent is  the  association  of  ascites  with  benign  ovarian  growths  such 
as  fibroma  and  multilocular  cyst.  I  have  no  idea  why  a  small  ovarian 
fibroma  without  metastases  should  produce  extensive  ascites  so 
frequently. 

Why  should  a  small  percentage  (7.9  per  cent.)  of  cystic  tumors 
produce  ascites?     One  would  expect  to  find  it  in  all  cases  or  in  none. 

Chart  VI. — Percentage  of  Ascites  Occurring  in  the  Different  Varieties  of  Ovarian  Tumor. 

No.  of  Ascites  found  at 

Diagnosis.                                                             cases.  .  operation  in — 

Ovarian  fibroma 20  50     per  cent. 

Ovarian  cancer 54  40            " 

Ovarian  sarcoma 5  20            " 

Ovarian  cystoma 391  7.9          " 

Among  14  cases  operated  upon  for  parovarian  cyst  no  ascites  was 
found  in  any. 


656  DIFFERENTIAL  DIAGNOSIS 

Case  292 

A  housekeeper  of  forty-eight  entered  the  hospital  July  17,  1909. 
She  entered  with  a  diagnosis  from  the  Out-patient  Department  of 
"ascites,  cause  unknown."  Nephritis,  malignant  disease,  tuberculosis, 
and  adherent  pericardium  were  suggested.  Family  history  negative. 
The  patient  has  always  been  delicate,  and  when  six  years  old  was  pro- 
nounced tuberculous  and  sent  to  the  country,  with  great  benefit. 
Fifteen  years  ago  she  had  a  bad  cough,  with  "ulcer  in  her  throat"  and 
loss  of  weight.  She  went  to  Vermont  for  two  months,  improved  very 
much,  and  has  been  better  ever  since,  though  eight  years  ago  she  had  a 
"nervous  breakdown,"  and  six  years  ago  the  glands  in  her  neck  became 
large  and  inflamed.  They  were  opened  and  drained  at  the  Homeo- 
pathic Hospital.  Following  this  operation  the  left  arm  became  stiff 
and  paralyzed,  though  the  power  gradually  returned  afterward.  She 
has  never  been  strong  since  then. 

When  first  married  she  had  two  miscarriages,  no  children.  Four- 
teen months  ago  she  passed  the  menopause  without  incident.  A  year 
ago  her  face  began  to  be  swollen,  and  soon  after  that  a  swelling  was  noticed 
in  the  abdomen.  Four  months  ago  the  legs  became  swollen,  but  the 
feet  did  not  swell  until  two  months  ago.  Five  weeks  ago  she  had  to 
take  to  bed.  She  has  had  no  pain,  save  an  occasional  "catch"  in  the 
lower  right  chest,  which  she  has  had  on  and  off  for  years.  She  is 
gaining  in  weight,  but  thinks  she  has  lost  flesh.  She  has  had  no 
cough. 

Physical  examination  showed  poor  nutrition,  pupils  slightly  irregu- 
lar, otherwise  normal.  Heart  negative,  impulse  shifting  i  cm.  with 
change  of  position.  All  the  evidences  of  fluid  in  the  abdomen.  Nor- 
mal reflexes.  On  the  i8th  the  abdomen  was  tapped.  Five  pints  of 
fluid  were  obtained,  pale,  opalescent,  1008  in  specific  gravity,  with  a 
sediment  containing  85  per  cent,  small  lymphocytes.  After  tapping 
the  edge  of  the  Hver  could  be  plainly  felt,  sharp,  hard,  and  apparently 
not  irregular.  The  blood,  urine,  and  blood-pressure  were  all  normal. 
The  patient  had  no  fever  in  two  weeks'  observation.  The  Wasser- 
mann  reaction  was  negative.  The  fluid  rapidly  re-accumulated. 
Examination  of  the  stomach  with  a  stomach-tube  showed  nothing 
abnormal. 

Discussion. — On  the  25  th  of  July  I  summed  up  the  evidence  as 
follows:  "Neoplasm  seems  the  most  probable  diagnosis,  although  there 
are  no  masses  or  pressure  symptoms  nor  any  organ  markedly  depressed 
in  function.     The  urine  is  not  characteristic  of  any  type  of  nephritis, 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  657 

and  the  absence  of  cardiac  enlargement,  high  blood-pressure,  and 
uremic  symptoms  make  nephritis  unlikely  as  a  cause  of  the  ascites. 

Tuberculous  peritonitis  seems  unlikely,  since  there  is  no  fever,  no 
local  tenderness  or  spasm,  and  since  the  fluid  has  re-accumulated  so 
rapidly.  Cirrhosis  is  possible,  but  improbable,  on  account  of  the  ab- 
sence of  alcoholic  history,  the  rapidity  of  the  re-accumulation,  and 
absence  of  toxemia.     The  patient  certainly  looks  cancerous." 

On  the  27  th  the  patient  was  transferred  to  the  surgical  service  and 
the  abdomen  opened.  A  large  amount  of  ascitic  fluid  was  evacuated, 
but  the  exploration  showed  nothing  abnormal  in  any  part  of  the 
abdomen  except  a  few  hard  white  nodules,  the  size  of  peas,  in  the 
liver.  One  of  these  was  excised  and  examined  by  Dr.  Maurice  H. 
Richardson,  who  made  a  diagnosis  of  "cirrhosis  of  the  liver."  There 
were  contracted  places  in  the  liver,  suggesting  scars.  The  diagnosis 
recorded  on  the  surgical  history  is  "s5^hilis  of  the  liver."  The  patient 
was  transferred  to  the  medical  side  and  was  given  mercurial  inunctions 
and  iodid  of  potash.  Nevertheless  the  abdomen  rapidly  refilled; 
6  quarts  were  removed  on  the  19th  and  5  quarts  on  the  23d.  The 
character  of  the  fluid  was  essentially  that  previously  reported. 

Outcome. — She  left  the  hospital  September  ist  and  died  September 
4th.  Hepatic  cirrhosis  of  syphilitic  origin  seems,  on  the  whole,  the 
most  reasonable  diagnosis. 

Case  293 

A  housewife  of  twenty-seven  entered  the  hospital  November  15, 
1909.  Five  months  ago  the  patient  began  to  notice  soreness  in  the 
lower  abdomen,  which  soon  after  swelled,  and  has  since  grown  steadily 
and  rapidly  in  size.  Except  for  this  she  has  had  practically  no  symp- 
toms, though  occasionally  she  vomits.  Her  appetite  is  good  and  her 
bowels  regular.  Her  menstruation  is  normal,  but  she  has  lost  consider- 
ably in  weight  and  strength.  Five  months  ago  she  weighed  158  pounds ; 
now,  132  pounds.  Nevertheless,  she  is  not  emaciated  even  now.  Her 
family  history  and  past  history  are  excellent. 

Physical  examination  was  negative  except  as  relates  to  the  ab- 
domen, which  showed  shifting  dulness  in  the  flanks.  Blood  showed  75 
per  cent,  hemoglobin  and  sHght  achromia  in  the  smear.  Urine  nega- 
tive. No  fever.  On  the  17th  9^  quarts  were  removed  from  the  abdo- 
men, and  after  this  tapping  a  mass  the  size  of  an  orange  could  be  felt 
low  down  on  the  right  side  of  the  abdomen.  It  was  not  tender,  and 
suggested  the  feel  of  a  closely  packed  bunch  of  grapes.  A  similar  but 
smaller  mass  was  felt  on  the  left.     The  mass  was  easily  felt  bimanually 

Vol.  11—42 


658  DIFFERENTIAL  DIAGNOSIS 

on  each  side  of  the  uterus,  which  itself  seemed  normal.  The  tap  fluid 
was  greenish  yellow,  opalescent,  alkaline,  1019  in  specific  gravity,  4.4 
per  cent,  albumin,  with  63  per  cent,  endothelial  cells,  33  per  cent, 
lymphocytes,  and  4  per  cent.  poljTiuclears  in  the  sediment. 

Discussion. — The  clinical  picture  is  of  slight  anemia  and  ascites  in 
a  woman  of  twenty-seven.  Nothing  definite  could  be  said  until  after 
tapping,  which  showed  a  high  gravity  fluid  such  as  we  should  expect 
in  neoplastic  peritonitis  or  tuberculosis  of  the  peritoneum.  Between 
these  two  diseases  the  mass  felt  low  down  near  the  pelvis  should  make 
us  strongly  favor  neoplasm.  It  is  true  that  tuberculous  peritonitis 
may  produce  abdominal  masses,  but  they  are  rarely  in  this  situation. 
Moreover,  we  have  no  fever  and  nothing  in  the  family  history  or  pre- 
vious history  to  suggest  tuberculosis.  The  diagnosis,  therefore,  should 
be  of  a  pelvic  neoplasm,  which  in  this  situation  is  almost  certainly  of 
ovarian  origin.  Whether  it  is  benign  or  malignant  only  histologic 
examination  can  decide. 

Outcome. — At  operation,  November  20th,  the  uterus  and  ap- 
pendages were  found  bound  up  in  one  large  mass  of  tissue,  resembling 
that  of  a  papillary  cyst  adenoma.  The  whole  mass,  including  the 
uterus,  was  removed.  Examination  showed  both  ovaries  cystic,  with 
numerous  papillary  outgrowths,  some  of  which  are  growing  freely  from 
the  peritoneal  surfaces.  Microscopic  examination  showed  a  fibrous 
structure  in  papillary  form,  the  surface  of  which  was  covered  by  a 
single  layer  of  rather  long  cylindric  epithelial  cells.  Diagnosis,  papil- 
lary cyst  adenoma.  The  patient  did  well  after  operation,  left  the 
hospital  December  9th,  and  a  year  later,  December  13,  19 10,  seemed  to 
be  entirely  well. 

Case  294 

A  barber  of  forty-nine  entered  the  hospital  April  18,  1910.  The 
patient's  father  died  of  paresis  at  forty-seven,  after  an  illness  of 
three  years.  His  mother  died  of  cancer  of  the  breast.  His  wife 
has  had  tuberculosis  and  has  been  in  a  sanitarium  fifteen  months 
for  it. 

The  patient  himself  has  never  had  a  sick  day  until  February  5, 19 10, 
when  he  had  a  chill,  followed  by  severe  pains  in  his  neck  and  breast- 
bone, with  sHght  cough  and  fever.  He  was  in  bed  four  weeks,  and 
after  he  had  been  up  a  few  days  his  feet  and  legs  began  to  swell  and  he 
began  to  be  short  of  breath.  Both  these  symptoms  have  steadily 
increased  since,  and  he  has  had  to  sleep  in  a  steamer  chair  for  more  than 
a  month.     For  two  weeks  he  has  had  a  sHght  cough,  but  he  no  longer 


ASCITES   AND   ABDOMINAL  ENLARGEMENT 


659 


has  any  pain.     Three  weeks  ago  he  began  to  notice  enlargement  of  his 
abdomen. 

On  physical  examination,  the  patient  was  obese,  skin  pale  and 
cyanotic.  Heart's  impulse  felt  in  the  fifth  space,  3  cm.  outside  the 
nipple  line,  the  right  border  dulness  4  cm.  from  midsternum.  Sounds 
feeble,  rapid,  regular,  no  murmurs  or  accentuations.  Systolic  blood- 
pressure,  155  to  180  during  the  week  of  his  stay  in  the  hospital.  The 
lungs  and  abdomen  as  shown  in  Figs.  235,  236.  Spleen  never  felt.  The 
whole  body  is  more  or  less  edematous,  the  legs  especially  showing  a 


F 

P"W 

g--          ■■   ■ ^ -2 

e" 

s^._ 

--r:-:-^ 

'■^ — 

V- 

- 

P'. 

g '    ■■  '■■' 

k- 

«^: 

"«■ 

^t-- 



'• 

-— 

Fig.  235. — Physical  signs  in  Case  294. 


hard,  brawny  swelling.  The  abdomen  was  tapped  on  the  i8th  and 
1600  c.c.  of  canary-yellow  turbid  fluid  obtained.  Specific  gravity  was 
1017;  albumin,  i  per  cent.  Sediment  contained  90  per  cent,  of  small 
mononuclears,  2  per  cent,  polynuclears,  the  remainder  of  the  endo- 
thehal  type.  On  the  20th  there  was  intense  bronchial  breathing  in  the 
left  back,  suggesting  a  pressure  area  as  in  pericarditis  or  hydropericar- 
dium.  The  whispered  voice  was  much  increased  and  there  was 
egophony. 

The  patient  remained  afebrile  and  fairly  comfortable  during  the  day, 


66o 


DIFFERENTIAL  DIAGNOSIS 


but  was  very  dyspneic  and  a  little  delirious  at  night,  especially  when 
he  slipped  down  off  his  bed-rest.  The  urine  examined  at  entrance 
showed  about  6  per  cent,  of  sugar  and  o.i  per  cent,  of  albumin.  The 
amount  was  not  increased  and  averaged  35  to  45  ounces,  and  the  sedi- 
ment showed  only  an  occasional  hyaline  or  granular  cast.  The  blood 
showed  13,500  leukocytes.  The  sugar  output  per  day  varied  between 
30  and  50  gm.  The  Wassermann  reaction  was  positive.  A  culture 
from  the  ascitic  fluid  was  negative. 

On  the  23d  he  had  a  fairly  comfortable  day,  though  he  dozed  a 
good  deal.  On  the  night  of  the  24th  he  suddenly  became  cyanotic  and 
pulseless,  and  within  an  hour  was  dead.     There  was  no  autopsy. 


Fig.  236. — Physical  signs  in  Case  294. 


Discussion. — The  family  history  is  variegated  and  interesting,  but 
not  of  special  significance,  so  far  as  I  see,  in  connection  with  the 
present  symptoms  of  the  patient,  which  point  to  a  postinfectious  car- 
diac trouble  associated  with  hypertension. 

The  specific  gravity  of  the  tap-fluid  is  not  like  that  of  an  ordinary 
dropsy.  On  the  other  hand,  the  amount  of  albumin  is  smaller  than 
that  which  we  expect  in  fluid  of  any  other  kind.  With  a  positive 
Wassermann  reaction  any  such  cardiac  weakness  should  be  regarded  as 
very  possibly  syphilitic,  especially  as  we  have  no  conclusive  evidence 
of  any  other  type  of  heart  trouble. 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  66l 

The  condition  of  the  urine  is  perfectly  consistent  with  this  hypoth- 
esis. We  may  suppose,  then,  that  he  has  a  syphilitic  nephritis  and 
myocarditis;  possibly  also  a  syphilitic  hepatitis.  A  similar  affection 
of  the  pancreas  might  be  conjectured  as  a  reason  for  the  glycosuria. 
Yet  surely  he  did  not  die  of  diabetes.  The  glycosuria  was  only  a  minor 
item  in  his  trouble. 

I  am  also  quite  sure  that  he  did  not  die  of  tuberculosis.  The  course 
of  the  illness  is  far  too  short  and  afebrile. 

Malignant  disease,  too,  may  be  clearly  excluded.  Just  how  far  the 
lesions  of  the  heart,  kidney,  and  liver  may  have  separately  contributed 
to  the  accumulation  of  ascites  it  is  impossible  to  say. 

Case  295 

A  bricklayer  of  twenty-three  entered  the  hospital  November  30, 
1910.  Three  of  the  patient's  brothers  died  of  Bright's  disease,  one 
sister  of  congenital  heart  trouble;  otherwise  the  family  history  is  good. 
The  patient  had  a  hard  chancre  last  February,  and  was  treated  by  in- 
unctions of  mercury,  mercurial  pills,  and  iodid  of  potash  from  April  to 
October  of  the  present  year.  In  April  he  had  a  sore  throat,  loss  of 
hair,  swelling  and  tenderness  of  the  cervical  lymph-glands,  and  severe 
lumbar  pains,  the  latter  lasting  two  weeks  and  disabling  him  for  that 
period  from  work. 

Five  weeks  ago  he  noticed  that  his  trousers  were  getting  tight  and 
his  legs  beginning  to  swell.  In  a  week  he  could  hardly  walk  because  of 
the  swelling.  He  gave  up  work  and  went  to  bed  for  a  week,  after  which 
the  swelling  was  reduced  on  a  milk  diet.  He  got  up  and  the  swelling 
then  reappeared  within  a  few  days.  Since  then  he  has  been  in  bed,  off 
and  on,  without  any  permanent  benefit.  He  never  passes  urine  at 
night  and,  aside  from  the  edema,  has  no  symptoms,  except  three  slight 
headaches  within  the  past  month  and  some  dimness  of  vision  in  the  last 
two  days. 

Physical  examination  showed  normal  pupils  and  reflexes,  notable  en- 
largement of  the  cervical,  axillary,  and  epitrochlear  lymph-nodes,  which 
were  hard,  the  smallest  the  size  of  a  pea.  The  heart  was  negative  and 
the  lungs  as  in  Fig.  237.  Abdomen  showed  dulness  in  the  flanks,  shift- 
ing with  change  of  position.  The  fundus  oculi  was  normal.  Urine  dur- 
ing his  eight  weeks'  stay  in  the  hospital  averaged  50  ounces  in  twenty- 
four  hours,  with  a  specific  gravity  of  1022.  The  amount  of  albumin 
varied  between  a  large  trace  and  0.6  per  cent.  The  sediment  showed 
very  large  granular  casts  and  a  few  hyahnes.  Systolic  blood-pressure 
was  never  above  125  mm.  Hg.,  usually  120  mm.  Hg.  or  lower;  at  en- 


662 


DIFFERENTIAL  DIAGNOSIS 


trance,  no  mm.  Hg.  Blood  was  normal.  Toward  the  latter  part  of 
his  stay  the  number  of  casts  in  his  urine  decreased  somewhat,  but  the 
albumin  ranged  between  0.4  and  0.7  per  cent.  Wassermann  reaction 
was  negative  on  the  7th  and  12th  of  January.  Daily  hot-air  baths  and 
purgation  with  magnesium  sulphate  had,  for  the  first  ten  days,  no  con- 
siderable effect  upon  the  edema  and  ascites.  No  cardiac  hypertrophy 
could  be  made  out.  By  the  12th  of  December,  1910,  the  edema  and 
ascites  began  to  go  down.  The  girth  at  the  navel  was  then  87  cm.; 
on  the  24th  of  December,  girth  84  cm.;  January  5th,  191 1,  girth  81  cm. 


Fig.  237. — Physical  signs  in  Case  295. 

January  8th  no  demonstrable  fluid  in  the  abdomen.     He  noticed  that 
he  passed  more  urine  whenever  he  stayed  in  bed. 

Discussion. — When  I  studied  this  patient  in  the  hospital  I  was 
amazed  at  the  combination  of  low  blood-pressure  with  obvious  urinary 
evidence  of  nephritis.  I  did  not  at  that  time  realize  that  the  degen- 
erative tubular  lesions  often  associated  with  syphiKs  may  produce  just 
this  combination  of  S5nnptoms,  the  type  of  lesion  classified  by  Volhard^ 
as  a  nephrosis.     As  in  the  previous  case,  we  may  be  in  some  doubt  how 

*  Die  Brightische  Nierenkrankheit,  von  F.  Volhard  und  Th.  Fahr,  von  Julius  Springer, 
Berlin,  1914. 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  663 

much  was  contributed  by  the  kidney  and  how  much  by  the  liver  to  the 
accumulation  of  ascites  in  this  case. 

Outcome. — January  17,  1910,  girth  78  cm.  January  22d,  practi- 
cally no  edema,  even  when  he  is  up  and  about.  Is  feeling  considerably 
better  and  wants  to  go  home.     Accordingly  he  is  discharged. 

Two  years  later,  January  2,  1913,  he  writes:  "I  have  been  steadily 
improving  since  I  left  the  hospital.  Last  August  when  I  took  neosal- 
varsan  I  had  my  urine  tested  and  there  was  a  faint  trace  of  albumin. 
Last  week  I  had  it  tested  again  and  there  wasn't  any  albumin.  I  have 
taken  salvarsan  four  times  and  seem  to  feel  better  after  taking  it." 

The  nephrosis  may  have  cleared  up  or  it  may  have  reached  the 
stage  of  "contracted  kidney,"  which  (according  to  Volhard)  follows 
in  some  cases  of  this  type,  as  well  as  in  the  glomerular  and  vascular 
types  of  disease. 

Case  296 

A  woman  of  twenty-one  entered  the  hospital  June  15,  191 1.  The 
patient's  father  died  of  cancer  of  the  stomach  at  sixty-two,  otherwise 
the  family  history  is  excellent.  She  has  had  no  previous  illnesses  until 
May,  1903,  when  she  was  much  pulled  down  by  an  attack  of  mumps 
and  whooping-cough,  her  cough  lasting  until  July.  Then  she  was  well 
until  September,  when  she  noticed  a  painless  enlargement  of  the  abdo- 
men, and  three  weeks  later  was  tapped,  8  quarts  being  withdrawn. 
She  was  tapped  three  times  more  before  March,  1904,  when  she  went  to 
the  Boston  City  Hospital  and  had  two  operations,  preceded  by  measles. 
The  second  operation  was  said  to  have  been  on  the  liver.  The  nature 
of  the  first  one  was  not  known.  After  that  time  she  was  tapped  only 
about  once  a  year,  12  to  15  quarts  of  clear  yellow  fluid  being  with- 
drawn each  time.  She  has  had  at  no  time  any  pain  and  her  bowels 
have  been  regular.  She  has  lost  no  weight  and  has  felt  strong  and  well 
most  of  the  time,  though  just  before  each  tapping  she  has  had  some 
dyspnea  and  edema  of  the  legs. 

Physical  examination  showed  good  nutrition,  very  dry  skin,  marked 
dulness  in  the  flanks,  shifting  with  change  of  position,  soft  edema  of  the 
legs,  flatness  below  the  angles  of  the  scapulae,  with  diminished  breath 
sounds  and  voice  sounds.  The  apex  impulse  of  the  heart  not  made  out, 
apparently  displaced  to  the  left  and  upward.  A  blowing  systoKc 
murmur  was  heard  at  the  apex  and  transmitted  over  the  precordia. 
The  pulmonic  second  was  accentuated.  Knee-jerks  were  not  ob- 
tained. Pupils  normal.  Urine  normal  at  entrance  and  most  of  the 
time  thereafter,  though  occasionally  it  contained  a  very  slight  trace 


664 


DIFFERENTIAL   DIAGNOSIS 


of  albumin.  Blood  normal.  Systolic  blood-pressure,  120.  Weight 
at  entrance,  155  pounds;  at  discharge,  six  weeks  later,  156  pounds. 
A  letter  received  from  the  Boston  City  Hospital  stated  that  she 
was  admitted  there  June  28,  1904,  with  a  diagnosis  of  tuberculous 
peritonitis  and  operated  upon  June  29th,  when  considerable  ascites 
was  found,  with  a  normal  liver  and  spleen.  Tubercles  were  found 
on  the  sigmoid  flexure.  The  second  operation,  August  4th,  showed 
nothing  but  a  considerable  amount  of  ascites. 


Spates 
tywloany 


Fig.  238. — Signs  in  Case  296. 


The  abdomen  was  tapped  at  the  Massachusetts  General  Hospital 
on  the  2ist  of  June  and  17  quarts  of  fluid  withdrawn.  Specific  gravity, 
1007 ;  albumin,  i  per  cent. ;  sediment,  endothelial  cells;  culture  negative. 
After  I  mg.  of  tuberculin  she  had  a  typical  temperature  reaction,  with 
considerable  cyanosis.  On  the  26th  she  was  given  100  gm.  levulose  in 
oatmeal,  but  the  urine  showed  no  sugar  thereafter.  X-ray  of  the 
shins,  June  25th,  showed  nothing  abnormal.  Wassermann  reaction 
was  negative  June  i6th.  Dr.  F.  G.  Balch  advised  no  surgical  inter- 
ference. At  entrance,  June  i6th,  I  made  the  diagnosis  of  cirrhosis  of 
the  liver;  later  chronic  fibrous  peritonitis  seemed  more  probable. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT 


66s 


She  was  discharged  the  27th  of  July  and  re-admitted  February  29, 
191 2,  after  being  tapped  meantime  every  eight  or  nine  weeks  at  first, 
later  every  four  weeks,  and,  later  still,  every  three  weeks.  For  the 
past  month  she  has  complained  of  much  gas  in  her  stomach,  with  loss 
of  appetite,  vomiting  and  dyspnea,  especially  at  night.  For  a  month  she 
has  remained  in  bed  and  has  lost  weight.  Two  days  ago,  at  9  P.  M., 
she  had  sudden  intense  pain  in  the  left  lower  back  and  began  to  cough, 
raising  bright  blood. 

Physical  examination  showed  marked  cyanosis,  lungs  and  abdomen 
as  in  Figs.  238,  239.     The  abdomen  obviously  contained  much  fluid. 


i l)r\j    Squeaks. 

Y\nt   VvioisT 


BreciTVi'iYio 
vevy 

sligV)tl  Y 
5\yv>(y\i%Vift5 


laTea-TWiVM 


Fig.  239. — Signs  in  Case  296. 


Knee-jerks  were  present  and  equal.  There  was  marked  systolic  re- 
traction of  the  lower  precordial  spaces,  suggesting  mediastinitis. 
There  was  also  a  paradoxic  pulse. 

Discussion. — The  insidious  onset  of  ascites  in  an  afebrile  patient  of 
fourteen,  and  in  quantity  sufficient  to  require  repeated  tappings,  with- 
out any  marked  impairment  of  the  general  health,  is  an  unusual  clinical 
picture.  There  is,  however,  one  well-recognized  cause  to  which  it  may 
be  due — namely,  adhesive  pericarditis. 

Although  the  records  of  the  Boston  City  Hospital  state  that  the 
patient  had  tuberculous  peritonitis,  the  details  of  the  record  are  not  at 


666  DIFFERENTIAL   DLA.GNOSIS 

all  convincing.  One  does  not  expect  to  find  any  such  process  confined 
to  the  sigmoid  flexure  or  to  any  other  one  part  of  the  intestine. 

When  at  the  Massachusetts  General  Hospital  the  characteristics  of 
the  tap-fluid  were  clearly  those  of  a  transudate,  not  of  a  peritonitis. 
The  positive  tubercuhn  reaction  obtained  at  this  time  is  not  of  impor- 
tance in  a  patient  of  twenty-one.  Mitral  regurgitation  would  have 
been  the  diagnosis  made  by  many,  in  view  of  the  physical  signs  at  this 
period.  I  wish,  however,  to  insist  strongly  that  such  a  diagnosis  is 
never  justified  as  the  chief  or  main  explanation  of  any  set  of  symptoms 
whatever.  Mitral  regurgitation  may  often  be  a  subordinate  item  in  a 
pathologic  state,  an  item  like  pulmonary  congestion  or  ulcer  of  the  leg, 
but  it  is  never  a  sufficient  or  primary  cause  for  other  symptoms. 

At  the  time  of  the  second  entrance  the  patient  had  evidently  had  a 
period  of  failing  compensation  and  a  recent  lung  infarct. 

The  evidence  presented  at  the  time  would  lead  any  unprejudiced 
observer  straight  to  the  diagnosis  of  adhesive  pericarditis.  The  only 
missing  link  is  the  lack  of  any  rheumatic  history. 

Outcome. — She  did  not  improve  at  all,  and  died  March  ist. 
Autopsy  showed  chronic  adhesive  pericarditis,  chronic  perihepatitis, 
perisplenitis,  chronic  peritonitis,  h3^ertrophy  and  dilatation  of  the 
heart,  infarct  of  the  left  lung,  infarcts  of  the  kidneys,  chronic  pleuritis. 

Case  297 

A  married  woman  of  forty  entered  the  hospital  August  26,  191 1. 
Her  family  history  is  negative,  and  she  remembers  no  serious  illness 
since  childhood.  She  has  been  married  fifteen  years  and  has  one  child 
living  and  well.  Has  had  no  miscarriages.  Her  habits  are  excellent. 
She  has  never  taken  alcohol. 

One  year  ago  she  had  what  she  calls  "gastritis"  for  a  week,  and  for 
four  or  five  days  afterward  her  skin  was  yellow,  but  there  was  no  itching. 
She  was  not  in  bed,  but  since  then  has  not  felt  quite  so  strong  as  before, 
and  her  abdomen  has  often  been  "bloated"  for  a  day  or  two.  The 
swelHng  has  disappeared  after  a  cathartic. 

Two  months  ago  the  swelling  in  the  abdomen  became  more  marked 
than  before  and  steadily  increased  until  three  weeks  ago,  when  she 
began  taking  salts  steadily.  Since  then  it  has  decreased  much,  but  a 
shortness  of  breath,  which  began  two  months  ago,  has  meantime  con- 
stantly increased.  For  the  past  month  she  has  had  a  dry  cough,  and 
finds  it  distressing  to  he  upon  the  right  side  at  night.  There  has  been 
no  pain  in  the  chest,  no  chills  or  fever,  no  return  of  the  jaundice,  no 
edema.     She  does  not  think  that  she  has  lost  any  weight  and  says  she 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  667 

has  always  been  thin.     For  years  it  has  been  her  habit  to  pass  urine 
four  or  five  times  in  the  night. 

Physical  examination  showed  poor  nutrition,  shght  dyspnea, 
moderate  pallor,  and  cyanosis.  Pupils  and  reflexes  normal.  No 
enlarged  glands.  Chest  and  abdomen  as  shown  in  Figs.  240-243. 
Urine  normal.  Blood  likewise  normal.  Wassermann  reaction,  Sep- 
tember 14th,  was  slightly  positive,  and  that  done  with  the  chest  fluid 
moderately  positive.  The  right  chest  was  tapped  August  26th,  August 
30th,  September  ist,  9th,  14th,  i8th,  23d,  and  30th.  It  did  not  need 
to  be  tapped  again  until  the  13th  of  October,  and  not  after  that  until 
some  months  later.     During  most  of  her  two  months'  stay  in  the  hos- 


^v\)  ■   Dry    Kif|Vi' 
bli-cW«.<^    ejclaivaTion 
.BvfiYichial   voice 


Dull  ro  flat.|^,p,,,  ..,.„;.,— .^  , .,  .    , 

a>5seiM   br-f,Al-h\vics,     /  Spate,  Yi\pHc 

VQies  CkVi  S -fvtm'iTUS  /         ,  li>ic. 

vtsistehce.  l\lo«Ar|€.  --  ^^^    sf>leeYi 

r  \anKs  \y}U 

?  ^luii   wave. 


Fig.  240. — Physical  signs  in  Case  297  at  entrance. 

pital  her  temperature  reached  99.3°  F.,  or  slightly  higher,  each  after- 
noon. The  pulse  ranged  in  the  neighborhood  of  1 10  for  the  first  month, 
after  that  lower,  and  for  the  last  two  weeks  of  her  stay  it  was  about  80. 
Her  weight  was  124  pounds  at  entrance,  104  pounds  on  the  15th 
of  September  and  at  the  time  of  her  discharge,  October  20th.  At 
all  of  these  tappings  of  the  chest,  referred  to  above,  the  specific  gravity 
of  the  fluid  varied  from  1004  to  1007.  Amount  of  albumin  was  i  per 
cent,  or  less;  the  sediment  mostly  of  endothelial  cells.  The  amount 
drawn  at  each  tapping  varied  from  2  to  4  quarts.  X-ray  examination 
added  no  new  evidence,  but  its  results  were  strongly  against  the  pres- 
ence of  any  mediastinal  tumor  or  any  primary  disease  of  the  lungs. 


668 


DIFFERENTIAL    DIAGNOSIS 


jQuH.  JHtnj  Ki^U- 

i+cKci  exfjiVatiOTv. 
Dro>f\cV\va\  vo\te 

'^      OLYvb   wW\<ober. 


Fig.  241. — Physical  signs  in  Case  297  at  entrance. 


?N^ 


Fig.    242. — Diagram    of    x-xzy    shadows.  Fig.  243.— Diagram  of  x-ray  plate  taken 

Plate  taken  with  patient  prone.  with  patient  sitting  up  and  immediately 

after  the  withdrawal  of  2\  quarts  of  fluid 
from  the  right  chest. 


The  spleen  was  always  felt  when  the  abdomen  was  moderately  relaxed. 
In  early  September  there  was  at  one  time  a  trifling  suggestion  of  exoph- 


ASCITES   AND   ABDOMINAL   ENLARGEMENT 


669 


thalmos,  and  the  rapid  unsatisfactory  beat  of  the  heart  slightly  sug- 
gested the  action  of  a  goiter  heart. 

On  the  20th  of  September  the  abdomen  was  thought  to  contain  a 
little  fluid,  although  no  absolute  flatness  could  be  obtained  in  the 
flanks.  It  was  accordingly  tapped,  but  only  40  c.c.  of  fluid  obtained, 
the  characteristics  being  practically  the  same  as  those  of  the  chest  fluid. 
Even  after  2 1  quarts  of  fluid  had  been  removed  from  her  chest  within 
four  weeks — to  September  23d — (Figs.  244,  245)  her  nutrition  was 
extraordinarily  well  maintained. 

About  the  first  of  October  she  was  put  upon  a  salt-free  diet  and  began 
to  improve  at  once.     At  the  tapping,  October  14th,  only  2  quarts  of 


Figs.  244,  245. — Condition  of  chest  September  23d  in  Case  297.    Anterior  and  posterior 


fluid  were  obtained.  She  left  the  hospital  October  21,  191 1,  and  re- 
ported regularly  thereafter.  January  13,  191 2,  three  months  after  the 
last  tapping,  there  was  no  evidence  of  any  considerable  amount  of  fluid 
in  the  right  chest,  but  the  abdomen  contained  a  moderate  amount  of 
fluid.  Her  only  complaint  now  was  a  moderate  degree  of  prolapse  of  the 
vaginal  wall.  She  notices  that  she  is  rapidly  gaining  weight  and  now 
weighs  III  pounds.     She  feels  excellently  well. 

Dr.  R.  B.  Greenough  suggested  the  possibiUty  of  ovarian  tumor,  and 
thought  this  possibiHty  would  justify  exploratory  incision.  Dr.  W.  H. 
Smith  thought  the  fluid  due  to  pressure  of  glands,  either  syphiHtic  or  of 
the  Hodgkin's  type.  As  an  alternate  diagnosis,  he  suggested  primary^ 
malignant  disease  of  the  abdomen,  possibly  of  the  ovary,  with  metas- 


670 


DIFFERNETIAL  DIAGNOSIS 


tases  in  the  right  lung.  Dr.  C.  H.  Lawrence  suggested  chronic  adhesive 
peritonitis  or  pleuritis,  syphilitic  in  origin,  but  could  not  rule  out  solid 
tumor  of  the  ovary.  Dr.  G.  C.  Shattuck  suggested  mediastinal  ob- 
struction due  to  old  polyserositis,  perhaps  syphilitic  or  tuberculous  in 
origin.  Dr.  F;  T.  Lord  suggested  perihepatitis,  with  peritonitis  and 
involvement  of  the  gastrohepatic  omentum  and  partial  occlusion  of  the 
portal  vein,  and  a  similar  process  in  the  mediastinum  and  pleura  with 
occlusion  of  the  right  azygos  vein.  Dr.  James  H.  Wright  thought  the 
hydrothorax  due  to  a  lesion  of  the  mitral  valve,  with  the  dilated  right 
heart  pressing  on  the  right  azygos  vein.  The  ascites,  he  said,  was  due 
to  cirrhosis  of  the  liver. 


T)oll.  LijD))Vvonvi. 

^rontUo-vesitular 
bveathiwo. 


Figs.  246,   247. — Physical   signs  in   Case  297  March  i,  191 2.     Anterior  and  posterior 

views. 

The  patient  re-entered  the  hospital  March  i,  191 2,  complaining 
chiefly  of  vaginal  prolapse,  with  bloating  of  the  abdomen.  Three  weeks 
ago  her  abdomen  became  especially  swollen.  She  took  an  active  purge, 
had  severe  watery  catharsis,  and  the  abdomen  became  flat,  but  she  was 
much  weakened.  She  was  in  bed  a  week  thereafter  and  has  not 
recovered  strength  since,  although  the  abdomen  has  again  become 
swollen.  The  condition  of  the  chest  and  abdomen  are  shown  in  Figs. 
246,  247.  Three  and  a  half  quarts  of  fluid  were  withdrawn  from 
the  chest,  the  properties  of  the  fluid  being  essentially  as  before;  i| 
quarts  were  also  withdrawn  from  the  abdomen  on  the  4th  of  March 
and  if  quarts  three  days  after.  The  chest  was  tapped  thereafter  on 
the  12th,  20th,  and  29th  of  March  and  on  the  5th  and  14th  of  April, 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  67 1 

the  amount  drawn  varying  from  3  to  4  quarts.  The  abdomen  was 
tapped  on  the  21st  of  March  and  i  quart  withdrawn;  on  the  28th  2 
quarts  were  withdrawn. 

On  the  13th  of  March  she  had  a  well-marked  temperature  reaction 
following  the  subcutaneous  injection  of  i  mg.  of  tuberculin.  Salt- 
free  diet,  which  helped  her  so  much  before,  had  now  no  effect.  On  the 
i6th  of  April  she  developed  an  erysipelas  around  the  last  tap-hole  in 
the  back.  Thereafter  she  lost  her  flesh  rapidly,  though  the  erysipelas 
cleared  up.     On  the  24th  of  April,  191 2,  she  died. 

Discussion. — The  multitude  of  conflicting  diagnoses  which  I  have 
recorded  in  this  case  shows  that  it  was  one  of  great  interest  and  diffi- 
culty. Throughout  the  whole  case  our  attention  was  concentrated 
upon  the  problem  of  explaining  the  rapid  re-accumulation  of  dropsical 
fluid  in  the  right  chest.  It  was  clearly  not  a  pleuritic  effusion,  for  its 
specific  gravity  was  far  too  low.  In  the  heart  we  could  find  no  sufficient 
cause  for  it.  The  x-ray  evidence  was  strongly  against  any  neoplasm 
such  as  lymphoblastoma.  No  nephritis  and  no  pelvic  tumor  could  be 
found.  (It  will  be  remembered  that  some  pelvic  tumors  are  associated 
with  hydro  thorax  as  well  as  with  ascites.) 

Insufficient  attention  was  paid  to  the  history  of  jaundice  and  to 
the  splenic  enlargement.  In  view  of  the  positive  Wassermann  reaction, 
my  attention  was  thrown  off  the  possibility  of  fiver  cirrhosis,  though,  in 
fact,  that  reaction  should  have  acted  rather  to  strengthen  such  a  possi- 
bihty.  As  a  matter  of  fact,  very  Kttle  attention  was  paid  to  the 
abdomen,  either  by  the  patient  or  her  physicians,  for  the  thoracic  symp- 
toms were  much  more  prominent. 

When  it  seemed  clear  that  we  could  exclude  the  heart,  the  kidney, 
tuberculous  peritonitis,  and  any  possible  neoplastic  source  of  pressure, 
I  skipped  over  the  fourth  common  cause  of  ascites,  namely,  hepatic 
cirrhosis,  and  alighted  on  a  much  more  uncommon  possibility,  namely, 
multiple  serositis.  Looking  back  with  the  knowledge  of  hindsight,  it 
is  easy  to  see  that  this  was  fooHsh;  yet,  even  after  the  autopsy,  the 
mystery  of  recurrent  hydro  thorax  was  never  cleared  up. 

Outcome. — Autopsy  showed  cirrhosis  of  the  liver,  enlargement  of 
the  spleen,  right  seropurulent  pleuritis,  obsolete  tuberculosis  of  the 
bronchial  lymphatic  glands,  streptococcic  septicemia. 

Case  298 

An  Italian  barber  of  thirty-six  entered  the  hospital  October  27, 
191 1.  The  patient  has  lost  one  brother  of  tuberculosis,  but  was 
not,  so  far  as  he  knows,  exposed  to  infection;  otherwise  his  family 


672  DIFFERENTIAL  DIAGNOSIS 

histoty  and  past  history  are  excellent.  For  fifteen  years  he  has 
taken  four  or  five  whiskies  and  three  or  four  beers  a  day.  He  had 
gonorrhea  ten  years  ago,  but  no  syphilis. 

Until  six  weeks  ago  he  has  felt  entirely  well.  Then  he 
was  seized  in.  the  night  with  vomiting  and  diarrhea.  Next  day  he 
went  to  work  and  felt  as  well  as  usual  for  two  weeks,  when  he  had  a 
second  similar  attack  without  known  cause.  He  returned  to  work, 
but  at  the  end  of  a  week's  work,  three  weeks  ago,  he  noticed  vague 
abdominal  discomfort  and  an  uncomfortable  sense  of  fulness  after 
eating  or  drinking,  even  in  moderation.  A  few  days  later  he  noticed 
that  his  abdomen  was  enlarged,  and  he  felt  so  weak  and  tired  that 
he  gave  up  work.  The  abdominal  enlargement  has  steadily  in- 
creased, and  within  a  few  days  he  has  noticed  some  puffiness  of  the 
ankles. 

His  bowels  have  been  constipated  and  have  required  cathartics. 
In  each  of  the  above  vomiting  spells  he  noticed  black  stools;  at 
other  times  there  has  been  nothing  abnormal  about  them.  He  has 
never  vomited  blood  and  has  had  no  stomach  symptoms  save  after  a 
drinking  bout.     His  appetite  is  still  fair. 

Physical  examination  showed  poor  nutrition,  normal  pupils  and 
reflexes,  normal  chest  save  for  a  few  fine  crackles  at  each  base.  Ab- 
domen showed  shifting  dulness  in  the  flanks  with  sKght  edema  of  the 
ankles.  Over  the  shins  were  many  large  areas  of  brownish  pigmenta- 
tion. Blood-pressure,  130  mm.  Hg.,  systolic;  85  mm.  Hg.,  diastolic. 
Wassermann  reaction  was  suspicious.  Urine  normal.  White  count 
at  entrance,  11,000;  November  ist,  19,000;  November  2d,  20,000; 
November  3d,  25,000;  November  6th,  22,000;  November  7th,  18,000; 
November  9th,  15,000;  November  nth,  13,000;  November  14th, 
10,500.  Through  the  ascitic  accumulation  a  hard,  apparently  smooth 
liver  could  be  felt  by  "dipping"  at  the  level  of  the  umbilicus.  Spleen 
not  felt.  In  the  fasting  stomach  there  was  a  good  deal  of  blood- 
stained materia] ,  with  a  positive  reaction  to  guaiac. 

The  tap-fluid  at  entrance  was  3800  c.c,  amber  color,  with  a  specific 
gravity  of  1012,  albumin,  2.4  per  cent.,  smear  chiefly  large  endothelial 
cells,  culture  negative.  Another  tapping,  November  3d,  showed  3300 
c.c. ;  specific  gravity,  loio;  albumin,  3  per  cent. ;  sediment,  70  per  cent, 
of  small  lymphocytes,  20  per  cent,  of  polynuclears,  10  per  cent,  endo- 
thelial cells,  no  growth  on  culture-media.  The  results  of  blood-cul- 
ture during  the  febrile  attack  are  shown  in  Fig.  248.  It  was  negative 
November  2d  and  November  9th.  Weight,  November  i6th,  127 
pounds;  November  2 2d,  after  three  tappings,  the  fluid  seemed  to  be 


ASCITES   AND   ABDOMINAL  ENLARGEMENT 


673 


accumulating  more  slowly.  Operation  was  advised,  but  postponed. 
The  patient  left  the  hospital  November  2 2d. 

He  came  back  again  December  26th  in  about  the  same  condition. 

Discussion. — When  an  Italian  of  thirty-six  admits  alcoholism 
and  gonorrhea,  his  denial  of  syphilis  is  of  no  special  importance;  and, 
joining  this  history  to  the  attacks  of  vomiting  and  black  stools 
and  the  four  weeks  of  swollen  abdomen,  which  examination  shows 
to  be  full  of  fluid,  we  naturally  think,  first  of  all,  of  hepatic  cirrhosis. 
The  cardiac,  renal,  neoplastic,  and  tuberculous  causes  of  ascites  are 
less  apt  to  be  associated  with  black  stools. 


o-j-to.  /  ,  II    III  III  ]i  ii-n  iu\  iiiiiii  II  III  II  II-  1  III  III  II-  1  11  II  II 

.BKBXKIclKMKHRKKlKaKaRaltHKIFSyiRIRHIIKKBaKIIRIBJVXBZBIBXIl 

10! 

108 

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Fig.  248. — Record  of  temperature,  pulse,  vuine  (in  ounces)^  respiration,  and  blood-cul- 
tures in  Case  298. 


The  tap-fluid  is  of  medium  weight,  but,  on  the  whole,  nearer  to 
that  of  a  transudate  than  that  of  an  inflammatory  fluid.  The  only 
discussable  question  relates  to  the  origin  of  the  cirrhosis.  The  suspi- 
cious Wassermann  reaction  and  the  brown  scars  upon  the  shin  rather 
incline  us  to  believe  that  the  trouble  is  syphiHtic.  The  fever  points 
in  the  same  direction.  Alcoholic  cirrhosis  is  less  Hkely  to  produce 
such  a  pyrexia.  None  of  the  other  causes  of  ascites,  except  tuber- 
culous peritonitis,  produce  fever.  Against  the  latter  are  the  condi- 
tion of  the  liver  edge  and  the  specific  gravity  of  the  fluid,  as  well  as 
the  negative  past  history  and  family  history. 

Outcome. — Operation  on   the  30th   showed   a   small  hob-nailed 

Vol.  11—43 


674 


DIFFERENTLA.L  DLA.GNOSIS 


liver.  Its  surface  and  that  of  the  peritoneum  near  it  was  scraped 
until  it  bled  and  the  two  surfaces  brought  into  apposition.  January 
4th  the  patient's  temperature  began  to  rise  and  continued  elevated, 
as  shown  in  Fig.  249.  There  were  many  rS,les  in  both  chests  and  he 
raised  a  large  amount  of  thick  sputa,  but  showed  no  signs  of  lung 
consolidation.  On  the  nth  he  had  to  be  tapped;  118  ounces  were 
removed.  On  the  25th  he  was  tapped  again  and  32  ounces  removed. 
After  that  the  abdomen  did  not  refill  and  the  patient  felt  much  better. 
On  the  6th  of  February,  191 2,  he  left  the  hospital  in  good  condition. 


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Fig.  249. — Chart  of  Case  298,  after  Talma's  operation. 

Remarks. — Apparently,  after  the  operation  he  suffered  a  pul- 
monary thrombosis.  His  subsequent  history  was  that  of  an  alcoholic 
loafer.  From  a  physical  point  of  view  the  operation  was  a  success; 
from  a  community  standpoint  we  can  hardly  say  so.  On  the  3d  of 
May  he  still  had  moderate  ascites,  but  was  greatly  improved  in 
general  appearance  and  had  gained  in  flesh  and  strength.  On  the 
31st  of  May  the  amount  of  fluid  in  the  abdomen  was  small,  but  August 
2ist  there  was  still  shifting  duhiess  in  the  flanks.  October  14,  1913, 
he  had  not  gone  to  work;  he  evidently  enjoyed  his  leisurely  life  far 
too  weU. 

Case  299 

A  clerk  of  twenty-four  entered  the  hospital  March  28,  1912.  The 
patient's  father  died  of  Bright's  disease.     Family  history  otherwise 


-      ASCITES   AND   ABDOMINAL   ENLARGEMENT  675 

excellent.  Three  years  ago  she  had  a  swelling  on  the  right  side  of  the 
neck  which  lasted  for  some  weeks.  Her  menstruation  has  been  rather 
profuse  for  the  past  year. 

For  five  months  she  has  been  gradually  getting  weaker  and  losing 
appetite,  but  has  had  no  more  definite  symptoms  than  these  until 
two  months  ago,  when  she  began  to  have  a  pain  between  her  shoulders 
and  down  both  arms.  In  the  course  of  another  month  this  gradually 
wore  off.  Four  weeks  ago  she  noticed  swelling  of  the  abdomen, 
which,  especially  in  the  last  two  weeks,  has  much  increased,  although 
for  the  same  period  she  has  had  three  or  four  watery  stools  a  day  and 
has  been  obliged  to  remain  in  bed.  She  has  considerable  pain  about 
her  heart  after  meals,  relieved  by  belching;  she  is  somewhat  short  of 
breath  on  exertion  and  when  attempting  to  lie  flat. 

Physical  examination  showed  considerable  wasting,  marked  sweat- 
ing, normal  pupils  and  reflexes,  normal  chest,  save  for  the  evidences  of  a 
high  diaphragm,  shifting  dulness  in  the  flanks,  blood-pressure  120  mm. 
Hg.,  blood  and  urine  normal.  On  the  29th  the  abdomen  was  tapped 
and  5^  quarts  of  fluid,  greenish  yellow  in  color,  withdrawn.  Specific 
gravity,  1018,  albumin  over  3  per  cent.  Smear  of  sediment  showed  45 
per  cent.  pol5niuclears,  55  per  cent,  large  and  small  mononuclears,  a 
few  red  blood-cells,  no  tubercle  bacilli;  20  minims  of  this  sediment 
were  injected  into  a  guinea-pig  March  29th.  On  the  6th  of  May  the 
animal  was  killed,  and  the  autopsy  showed  tuberculous  lesions  of  the 
glands,  Hver,  and  spleen.  After  tapping  there  was  still  slight  general 
spasm  of  the  abdomen  and  a  moderate  dull  pain  there.  Throughout 
her  three  weeks  in  the  medical  wards  the  temperature  continued  much 
elevated.  The  cutaneous  tuberculin  test  was  positive.  On  the  1 7th  of 
April  she  was  transferred  to  the  surgical  wards. 

Discussion. — Here  we  have  a  cUnical  picture  of  an  ascites  with- 
out any  evidence  of  renal,  cardiac,  hepatic,  or  neoplastic  origin. 
The  fluid  is  of  high  specific  gravity  and  produces  tuberculosis  in 
a  guinea-pig.  There  are  no  further  evidences  needed.  We  may 
be  as  certain  of  tuberculous  peritonitis  as  if  an  autopsy  had  been 
done. 

Looking  back  from  this  standpoint  of  certainty,  it  is  of  interest  that 
the  patient  had,  three  years  before,  a  swelling  in  the  neck,  which  we 
may  reasonably  interpret  as  a  tuberculous  gland.  This  followed  five 
months  of  the  sort  of  symptoms  ordinarily  kno"ViTi  as  general  debihty 
or  attributed  to  stomach  trouble.  Diagnosis  would  probably  have  been 
impossible  at  that  time,  but  the  lesson  to  be  learned  is  this:  when 
people  become  debilitated  without  any  good  reason  and  without  any 


676  DIFFERENTIAL   DIAGNOSIS 

demonstrable  physical  sign,  tuberculosis  is  always  a  plausible-cause  and 
should  be  watched  for  sedulously. 

Outcome. — At  operation  the  peritoneum  was  lusterless,  but  very 
few  tubercles  could  be  seen.  There  were  a  moderate  number  of  ad- 
hesions and  several  pockets  of  fluid,  which  were  not  opened.  Both 
Fallopian  tubes  were  found  to  be  tuberculous  and  were  removed.  In 
the  surgical  wards  she  continued  to  run  a  fever  from  April  17th  to  her 
discharge,  May  9th.  Microscopic  examination  of  the  excised  tubes 
showed  tuberculosis.     Her  general  condition  improved  somewhat. 

January  20,  19 13,  a  letter  from  her  sister  states  that  she  died 
June  30,  1912. 

Case  300 

A  housepainter,  aged  fifty-six  years,  who  had  taken  alcohol  only 
occasionally  and  in  moderate  amounts,  noticed  edema  of  his  ankles 
seven  weeks  ago.  A  week  later  his  belly  swelled  up,  and  he  needed 
three  tappings  in  sLx  weeks,  8  or  9  quarts  being  withdrawn  each 
time.     Has  lost  30  pounds  in  four  months. 

Examination. — The  right  lower  lid  contained  a  small  nodule 
showing  all  the  characteristics  of  epithelioma.  The  heart  was  dis- 
placed so  that  its  apex  was  in  the  anterior  axillary  line,  while  the 
right  border  of  dulness  was  at  the  left  sternal  margin.  There  was  a 
soft  systolic  murmur  at  the  apex.  The  pulmonic  second  sound  was 
not  accentuated. 

There  was  evidence  of  edema  at  the  bases  of  the  lungs.  The  belly 
contained  a  large  amount  of  serous  fluid,  250  ounces  accumulating 
between  two  tappings  sixteen  days  apart — an  average  of  over  15 
ounces  a  day.  The  fluids  were  1006  and  1008  in  gravity,  and  showed 
80  and  90  per  cent,  of  lymphocytes  respectively  in  their  sediments. 
Culture  and  animal  inoculation  negative.  Fever  was  absent,  and 
there  was  no  reaction  after  the  subcutaneous  injection  of  10  mg.  of 
tuberculin. 

There  was  some  excess  of  neutral  fat  in  the  stools,  suggesting  to 
Dr.  H.  F.  Hewes  the  stools  of  tuberculous  peritonitis. 

In  diagnosis  we  considered  cirrhosis  of  the  liver,  tuberculous 
peritonitis,  and  also  the  possibility  that  misplacement  of  the  heart, 
owing  to  pleural  adhesions,  might  have  kinked  some  one  of  the  great 
abdominal  veins  so  as  to  produce  stasis  and  ascites. 

Against  cirrhosis  was  the  early  appearance  of  swelling  in  the  legs 
and  the  moderate  amount  of  alcohol  ingested.  Against  tuberculosis 
was  the  negative  tubercuhn  reaction  and  the  low  gravity  of  the 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  677 

fluid  obtained  by  tapping.  On  the  other  hand,  the  cell-count  in  the 
fluid,  the  appearance  of  the  stools,  as  well  as  the  old  history  of  pleurisy, 
made  tuberculous  peritonitis  a  possibility.  On  the  whole,  cirrhosis 
seemed  the  more  probable,  and  on  operation,  September  i8th,  this 
was  found. 

Outcome. — The  patient  died  September  29th,  and  autopsy  showed 
the  ordinary  lesions  of  cirrhosis  of  the  Hver  and,  in  addition,  a  thrombo- 
sis of  the  portal  vein  and  a  chronic  peritonitis.  There  was  also  slight 
fibrous  endocarditis  of  the  aortic  and  mitral  valves  and  slight  hyper- 
trophy and  dilatation  of  the  heart.  There  was  obsolete  tuberculosis 
of  a  tracheal  lymph-gland,  which  is  interesting  in  view  of  the  negative 
tuberculin  reaction. 

Case  301 

A  married  woman,  aged  thirty-eight  years,  entered  the  hospital 
October  9,  1908.  She  has  previously  been  well  except  that  she  has 
had  a  cough  since  she  was  a  girl,  and  had  typhoid  fever  ten  years 
ago.  For  two  or  three  years  she  has  felt  something  wrong  in  the 
pelvis,  and  a  year  ago  her  doctor  found  a  uterine  fibroid  there.  The 
patient  thinks  this  tumor  has  been  present  for  four  years. 

Seven  months  ago  she  consulted  a  physician  for  pain  in  her  left 
chest.  He  found  pleural  effusion,  and  withdrew  2  quarts  of  fluid 
by  tapping.  The  same  amount  was  withdrawn  four  weeks  later, 
but  the  fluid  again  recurred. 

A  month  ago  the  abdomen  was  noticed  to  be  swelling,  and  this 
has  increased  up  to  the  present  time.  She  has  had  dypsnea  on 
exertion  for  many  years,  but  this  has  been  worse  within  the  last 
seven  months,  and  now  she  cannot  lie  down  flat.  For  the  last  two 
days  the  feet  and  legs  have  been  swelling.  The  bowels  move  five 
to  eight  times  a  day  during  the  last  few  weeks.  Several  examina- 
tions of  the  urine  and  several  of  the  sputa  have  been  negative. 

Physical  examination  verified  the  findings  of  fluid  in  the  left 
chest  and  in  the  abdomen.  October  loth  the  abdomen  was  tapped 
and  18  pints  of  serum  withdrawn.  The  specific  gravity  was  1018, 
and  the  cell-count  showed  63  per  cent,  of  lymphocytes. 

After  tapping,  a  rounded  solid  tumor,  hard  and  painless,  could  be 
felt  in  the  median  line,  apparently  connected  with  the  uterus.  The 
diagnosis  was  believed  to  be  tuberculous  peritonitis,  and  the  experiment 
was  tried  of  withdrawing  8  ounces  of  fluid  from  the  chest  every  two 
or  three  days,  in  order  to  prevent  recurrence  such  as  was  thought 
likely  to  follow  if  the  whole  amount  was  removed  at  once. 


678  DIFFERENTIAL  DIAGNOSIS 

On  November  21st  the  abdomen  was  again  tapped  and  18  pints 
again  removed.  This  amount  had  accumulated  in  forty-two  days, 
being  at  the  rate  of  7  ounces  a  day.  After  this  tapping,  pelvic  ex- 
amination showed  a  mass  filhng  the  pelvis,  pushing  the  cervix  up  behind 
the  pubes,  very  hard,  irregular,  non-elastic,  and  continuous  with  the 
suprapubic  tumor.  Dr.  M.  H.  Richardson  beheved  the  condition  to 
be  one  of  tuberculous  peritonitis  with  a  concomitant  uterine  tumor, 
benign  or  malignant. 

The  association  of  fluid  in  the  abdomen  with  fluid  in  the  chest, 
and  the  history  of  a  chronic  cough,  together  with  the  high  gravity 
of  the  fluid,  made  us  confident  of  the  diagnosis  of  tuberculous  peri- 
tonitis, although  in  the  two  and  one-half  months  of  her  stay  in  the 
medical  wards  there  was  never  any  fever.  The  blood  and  urine  were 
throughout  negative,  as  was  the  rest  of  the  visceral  examination. 

Outcome. — Operation,  December  12th,  showed  no  peritonitis,  but  a 
fibroma  of  the  ovary;  after  the  removal  of  this  the  patient  convalesced 
rapidly,  and  when  I  saw  her  a  year  later  she  was  in  perfect  health,  as 
she  had  been  for  the  last  eleven  months  since  leaving  the  hospital. 

Case  302 

An  unmarried  Italian  girl,  aged  seventeen  years,  entered  the  hos- 
pital October  17,  1908,  for  enlargement  of  the  abdomen,  with  fever 
and  general  abdominal  pain.  These  symptoms  had  been  present  for 
the  last  two  weeks  and  had  been  accompanied  by  a  dry  cough. 

On  examination  there  were  dulness  and  harsh  breathing  through- 
out the  left  lung  except  at  the  bottom  of  the  axilla  and  the  base 
posteriorly,  where  breathing  was  much  diminished  and  resonance 
almost  absent.  Below  the  second  left  interspace  were  fine  and 
medium  crackling  rales  in  front,  and  the  same  rales  were  heard  below 
the  angle  of  the  scapula  behind.  The  abdomen  showed  all  the  evi- 
dences of  free  fluid.  Otherwise,  physical  examination  was  negative, 
and  the  blood  and  urine  showed  nothing  abnormal. 

After  the  first  five  days  the  patient  had  practically  no  fever  through- 
out her  two  months'  stay  in  the  hospital.  The  abdomen  showed 
general  tenderness,  but  was  otherwise  negative,  save  for  the  evidences 
of  free  fluid  above  referred  to.  The  abdomen  was  tapped  on  the  21st, 
but  only  a  few  ounces  of  clear  serous  fluid  were  ob tamed;  5  mg.  tu- 
berculin were  injected  subcutaneously  on  the  30th,  after  which  the 
temperature  rose  from  normal  to  103.2°  F.  within  six  hours,  returning 
to  normal  within  twelve  hours  more.  The  cutaneous  reaction  for 
tuberculosis  was  also  positive. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  679 

She  gained  weight,  although  there  was  no  increase  in  the  amount 
of  fluid,  and  on  November  12th  was  ahowed  to  go  home. 

Outcome.— After  this  she  slept  out  of  doors  and  lived  out  of  doors 
continuously,  but  by  January  the  abdomen  began  to  enlarge  again, 
and  January  i6th  she  was  operated  on  and  diffuse  tuberculosis  of  the 
peritoneum  found.  Diagnosis  was  verified  by  microscopic  examina- 
tion of  an  excised  piece.  The  Fallopian  tubes  were  also  tuberculous 
and  were  removed.     Convalescence  was  uneventful. 

The  resemblance  between  this  case  and  that  last  described  is 
striking.  Indeed,  but  for  the  presence  of  the  tumor  in  the  first  case, 
the  abdominal  tenderness  and  the  scantiness  of  the  ascites  in  the 
second,  they  are  almost  identical  from  a  clinical  standpoint,  despite 
the  entire  difference  of  the  actual  pathologic  condition  present. 

A  relatively  slow  accumulation  of  fluid  and  a  slight  general  rigid- 
ity and  tenderness  of  the  belly  help  to  distinguish  the  ascites  of 
tuberculous  peritonitis  from  that  produced  by  other  diseases. 

Cass  303 

A  boy,  aged,  six  years,  entered  the  hospital  October  19,  1908. 
His  history  was  not  of  significance  up  to  five  months  previously, 
when  his  abdomen  began  to  swell;  there  was  also  some  puffiness  of 
the  face,  but  no  other  symptoms,  and  within  a  few  weeks  he  was 
able  to  be  up  and  about.  Later  he  relapsed,  and  two  months  ago 
the  abdomen  was  tapped,  4  quarts  of  dark  yellow,  turbid  fluid  being 
withdrawn. 

Since  this  there  has  been  considerable  vomiting,  and  at  one  time 
he  had  convulsions  and  was  considered  moribund.  He  was  tapped 
again  three  weeks  ago  and  3  quarts  of  fluid  withdrawn.  Since  then 
the  abdomen  has  rapidly  refilled. 

On  examination  the  cardiac  impulse  was  in  the  nipple  line,  fourth 
space.  The  cardiac  examination  was  otherwise  not  remarkable. 
Blood-pressure  not  measured.  The  lungs  were  negative,  the  abdo- 
men very  prominent,  showing  all  the  evidences  of  free  fluid.  Con- 
siderable soft  edema  of  the  legs  and  feet. 

The  urine  averaged  between  5  and  10  ounces  in  twenty-four  hours 
during  his  stay  in  the  hospital.  The  specific  gravity  was  between 
1020  and  1022;  the  amount  of  albumin  from  0.5  to  0.9  per  cent.  In 
the  sediment  were  many  hyaline,  granular,  and  fatty  casts. 

The  abdomen  was  tapped  on  October  21st  and  5  quarts  6  ounces 
of  chylous  fluid  withdrawn;  specific  gravity,  1009.  In  the  sediment, 
lymphocytes,  37  per  cent.;  epithelial  cells,  63  per  cent. 


68o  DIFFERENTIAL  DIAGNOSIS 

Outcome. — The  boy  left  the  hospital  on  November  2,  1908,  in  very- 
poor  condition,  and  remained  so  until  February,  1909,  when,  after 
tapping,  his  abdomen  did  not  refill,  and  this  improved  condition  per- 
sisted for  three  months.  Since  then  he  has  had  to  be  tapped  every  two 
weeks,  fifteen  times  in  all,  up  to  September  27th.  (An  average  accu- 
mulation of  about  12  ounces  a  day.) 

His  condition  in  September,  1909,  was  in  all  respects  essentially 
the  same  as  it  had  been  a  year  before,  except  that  the  heart  was  1.5 
cm.  farther  to  the  left.  He  was  tapped  on  the  28th  and  5  quarts 
(5800  c.c.)  of  opalescent  fluid  removed;  specific  gravity,  1006.  After 
this  the  fluid  re-accumulated  very  slowly,  and  he  was  allowed  to  go 
home  on  October  9th. 

Case  304 

A  dentist,  aged  thirty-nine  years,  entered  the  hospital  October 
20,  1908.  He  had  been  in  the  habit  of  taking  a  pint  and  a  half  of 
whisky  a  day  for  the  last  two  years,  and  an  unknown  amount  for 
eight  years  previously.  Two  and  one-half  months  ago  he  noticed 
that  his  trousers  were  tight  around  the  waist.  This  increased  so 
rapidly  that  four  weeks  later  the  abdomen  had  to  be  tapped,  and 
5  quarts  of  serous  fluid  were  withdrawn.  Since  then  he  has  been 
tapped  four  times,  the  amount  being  about  the  same  each  time. 
This  means  an  accumulation  of  about  16  ounces  a  day.  His  feet 
have  never  been  swollen,  his  appetite  has  been  good,  there  has  been  no 
pain  or  other  symptoms  of  any  kind.     The  last  tapping  was  a  week  ago. 

Physical  examination  was  essentially  negative  except  for  the 
evidences  of  ascites.  The  blood  and  urine  showed  nothing  abnormal. 
Temperature,  pulse,  and  respiration  were  normal.  October  27th,  14 
pints  7  ounces  of  turbid  yellow  fluid  were  withdrawn.  After  tapping, 
the  edge  of  the  liver  could  not  be  felt  below  the  ribs,  but  could  be 
touched  by  reaching  up  behind  the  costal  margin.  The  specific 
gravity  of  the  fluid  was  1008. 

Outcome. — On  October  28th  the  abdomen  was  opened,  the  liver 
found  to  be  shrunken  and  irregularly  nodular.  Omentopexy  was  done, 
but  by  November  9th  the  patient  had  to  be  tapped  again,  and  9  pints 
of  fluid  were  removed.     (Rate  of  accumulation,  12  ounces  a  day.) 

He  left  the  hospital  November  22,  1908.  November  29,  1909, 
the  patient  was  seen  and  seemed  to  be  in  excellent  condition.  There 
was  no  return  of  fluid  in  the  abdomen.  The  abdomen  was  tapped 
within  a  few  days  after  leaving  the  hospital  in  November,  1908,  but 
tapping  has  not  been  required  since.  He  now  eats  well,  sleeps  well, 
and  looks  well. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  68 1 

Case  305 

A  salesman,  aged  thirty-four  years,  entered  the  hospital  Novem- 
ber 13,  1908.  His  family  history  and  past  history  not  remarkable, 
habits  good.  For  four  or  five  years  he  has  been  gaining  weight  and 
has  noticed  that  his  trousers  were  tight  about  the  waist.  His  usual 
weight  is  150  pounds;  now,  158  pounds.  The  increase  of  his  girth  has 
been  especially  marked  in  the  last  year,  and  has  been  accompanied 
by  dyspnea  on  exertion.  During  the  last  ten  months  his  appetite  has 
also  failed;  he  has  had  a  good  deal  of  vomiting  soon  after  meals, 
also  troublesome  constipation.  He  worked  until  nine  months  ago. 
Eight  months  ago  he  was  tapped  and  6|  quarts  of  clear  fluid  removed. 
After  a  month  he  began  to  refill.  He  has  been  treated  during  the  last 
four  months  in  the  Out-patient  Department. 

Physical  Examination. — The  heart's  impulse  extended  2  cm. 
outside  the  nipple  line  in  the  fifth  space.  The  heart  sounds  were 
clear  and  there  was  nothing  else  of  interest  in  the  cardiac  condition. 
The  position  of  the  apex  shifted  outward  2.5  cm.  when  he  lay  on  the 
left  side.  The  peripheral  arteries  were  normal  and  the  lungs  nega- 
tive. The  abdomen  showed  all  the  evidences  of  free  fluid,  and  the 
"^dge  of  the  liver  could  be  felt  7  cm.  below  the  costal  margin  in  the 
mammary  line. 

He  was  tapped  November  20th;  202  ounces  of  yellow  turbid  fluid 
removed;  specific  gravity,  1020.  In  the  sediment  85  per  cent,  of 
small  lymphocytes,  15  per  cent,  of  large  lymphocytes.  Nothing 
more  felt  after  tapping.  After  an  injection  of  0.005  tuberculin  sub- 
cutaneously  there  was  a  positive  temperature  reaction.  The  x-rays 
showed  no  evidences  of  tuberculosis  in  the  lungs.  At  this  time  the 
spleen  was  easily  palpable  when  the  patient  lay  upon  his  right  side, 
and  it  was  noticed  that  there  was  a  systolic  retraction  of  the  apical 
and  precordial  region.  Adherent  pericardium,  tuberculous  perito- 
nitis, and  cirrhosis  were  considered,  but  laparotomy,  December  5th, 
showed  no  tuberculosis  and  no  evidence  of  disease  in  the  Hver  so  far 
as  the  surgeon's  hand  could  discover.  Dr.  M.  H.  Richardson  and 
Dr.  Hugh  Cabot  considered  the  case  to  be  probably  one  of  pericar- 
ditis with  adhesions  and  secondary  ascites. 

After  that  he  got  along  until  January  9,  1909,  with  two  tappings, 
but  was  then  operated  on  again,  January  loth,  for  the  relief  of  adherent 
pericardium.  Parts  of  the  third,  fourth,  and  fifth  ribs  were  resected 
from  their  sternal  attachments  to  a  point  4  inches  to  the  left.  This 
seemed  to  allow  the  free  retraction  of  the  heart,  and  was  deemed 
sufficient. 


682  DIFFERENTIAL  DIAGNOSIS 

He  returned  to  the  medical  wards  on  January  26,  1909,  and  under 
calomel  diuresis  the  urine  rose  to  68  ounces  and  the  amount  of  ascites 
was  considerably  decreased.  This  calomel  diuresis  was  repeated 
ten  days  later,  with  success  as  before.  On  March  4th  he  was  tapped, 
but  only  4  quarts  removed.  The  liver  edge  was  then  felt  5  cm.  below 
the  ribs.  The  specific  gravity  of  the  ascitic  fluid  was  1017.  March 
loth  he  was  tapped  again,  but  only  6  pints  found.  A  calomel  diuresis 
was  attempted  on  March  15th,  but  was  unsuccessful.  It  was 
evident  that  after  the  operation  for  cardiolysis  the  accumulation 
of  ascites  was  slower,  though  this  may  have  been  due  to  the  per- 
sistent administration  of  diuretics  and  cathartics.  He  was  last  seen 
March  27,  1909. 

Case  306 

A  Russian  Jewish  millgirl,  aged  eighteen  years,  entered  the  hospital 
December  2, 1908,  with  a  diagnosis  of  "tuberculous  peritonitis"  made  in 
the  Out-patient  Department  by  Dr.  W.  H.  Smith  (0.  P.  D.,  No. 
118,422).  Her  family  history  and  past  history  were  uneventful. 
Menstruation  began  at  twelve  and  has  been  regular  until  within  the  last 
year,  when  it  has  become  more  frequent,  and  lately  has  come  every  two 
weeks  and  lasted  four  days  each  time.  For  three  months  she  has  no- 
ticed enlargement  of  the  abdomen,  and  thinks  she  has  been  losing 
weight.  Within  the  last  month  she  has  had  some  abdominal  pain, 
paroxysmal  and  griping.  Her  appetite  has  been  good  and  there  has 
been  no  cough  or  other  symptoms.  Pulse,  temperature,  and  respira- 
tion were  moderately  and  irregularly  elevated.  The  urine  showed 
nothing  abnormal.  In  the  blood  were  17,900  leukocytes  per  cubic 
milHmeter  December  3d;  16,800  leukocytes  December  7th. 

Physical  examination  was  negative  except  as  relates  to  the  abdo- 
men, which  was  prominent,  tense,  fiat  on  percussion  throughout,  sym- 
metric, and  gave  a  fluid  wave.  Girth  at  the  umbiHcus,  86.5  cm.  The 
edge  of  the  Hver  was  not  felt.     No  edema. 

Tuberculous  peritonitis  was  considered,  but  the  leukocytosis  and 
the  extreme  tightness  of  the  belly  made  the  diagnosis  doubtful. 

Outcome. — December  4th  the  abdomen  was  tapped  above  the 
pubes  and  96  ounces  of  muddy,  thick,  viscid,  ropy,  alkaline  fluid 
obtained;  gravity,  1025.  The  fluid  resembled  very  thick  maple  syrup 
and  formed  a  jelly-like  mass  after  heating.  When  diluted  there  was 
no  precipitate  or  clot  obtained  by  heat  or  by  the  addition  of  acetic 
acid.  Biuret  reaction  negative.  The  addition  of  alcohol  produced 
a  heavy,  ropy,  tenacious  precipitate  (pseudomucin  and  paramucin). 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  683 

This  precipitate,  when  boiled  with  acid,  broke  up  into  two  bodies, 
one  of  which  reduced  Fehhng's,  while  the  other  gave  the  Biuret  reac- 
tion. In  the  sediment  there  was  nothing  distinctive.  The  fluid  was 
obviously  characteristic  of  the  contents  of  an  ovarian  cyst.  By  lapar- 
otomy a  large  multilocular  cyst  of  the  right  ovary  was  removed  with- 
out incident. 

Case  307 

A  housewife,  aged  thirty-seven  years,  entered  the  hospital  February 
15,  1909.  She  had  had  a  miscarriage  seven  and  one-half  years  ago, 
purposely  induced;  one  living  child  five  years  old.  Two  threatened 
miscarriages  in  the  course  of  this  pregnancy.  The  baby  was  anemic 
for  the  first  three  weeks,  but  otherwise  has  been  well.  The  patient 
had  diphtheria  twelve  years  ago,  and  the  throat  was  sore  for  six  weeks 
at  that  time.  Three  years  ago  began  to  have  pains  in  her  lower  legs, 
especially  along  the  shins.  The  pains  came  at  night,  were  very  severe, 
and  prevented  sleep.  There  were  no  enlarged  veins  or  other  noticeable 
changes,  but  the  bones  were  sore  to  the  touch.  A  year  later  some  ulcers 
appeared;  the  last  one  healed  three  months  ago.  Four  months  ago  she 
had  severe  pain  in  the  occiput,  worse  at  night,  and  at  this  time  three 
lumps  appeared  on  her  head  about  i  inch  in  diameter,  sore  to  the  touch. 
One  of  them  still  remains. 

Since  her  last  pregnancy  has  had  trouble  with  her  nose,  causing 
difficulty  in  breathing.  At  this  time  also,  about  five  years  ago,  her 
hair  came  out  profusely  for  a  time.  Two  or  three  years  ago  she  noticed 
a  tumor  in  her  left  h3rpochondrium,  which  caused  no  symptoms,  but 
bothered  her  in  putting  on  her  corsets.  Last  October  she  was  operated 
on  for  hemorrhoids,  and  at  that  time  the  doctor  said  that  her  spleen 
was  enlarged. 

Two  and  one-half  months  ago  the  belly  began  to  enlarge,  and  she 
has  been  tapped  twice,  six  weeks  ago  and  three  weeks  ago.  On 
examination  there  were  many  pea-sized  cervical  glands.  The  chest 
was  negative;  systolic  blood-pressure,  135.  The  upper  border  of  the 
liver  showed  on  percussion  a  median  elevation  just  above  the  nipple 
line.  The  edge  of  the  spleen  was  felt  12  cm.  below  the  ribs.  There 
was  evidence  of  free  fluid  in  the  abdomen,  and  the  girth  at  the  umbili- 
cus was  109  cm.  Considerable  soft  edema  of  the  ankles,  and  dark 
brown  scars  over  the  ankles  and  shins.  On  the  forehead  near  the  hair 
line  was  a  straight  periosteal  thickening,  and  another  higher  up  in 
the  hair  on  the  frontal  bone.  X-ray  plates  showed  specific  changes 
in  the  tibiae. 


684  DIFFERENTIAL  DIAGNOSIS 

Outcome. — Under  antisyphilitic  treatment  and  diuretin  the 
patient  improved  rapidly.  The  fluid  diminished  in  amount,  but  on 
March  2d  6  quarts  were  withdrawn,  after  which  the  edge  of  the  liver 
could  be  easily  felt  2  cm.  below  the  ribs  in  the  nipple  line.  The  ascitic 
fluid  was  1009  in  speciiic  gravity  and  showed  90  per  cent,  of  mononu- 
clear cells,  about  one-half  of  them  large  and  one-half  small.  She  left 
the  hospital  March  6,  1909,  and  up  to  date,  May  i,  1914,  has  remained 
well. 

Case  308 

A  shoemaker,  aged  fifty-three  years,  entered  the  hospital  Novem- 
ber 12,1 908 .  Family  history  and  past  history  not  remarkable .  Eight 
years  ago  lumps  appeared  in  the  left  side  of  his  neck,  and  have  not 
changed  since  then  until  a  year  ago,  when  additional  and  larger  lumps 
made  their  appearance  near  those  previously  felt.  Also  similar  lumps 
in  the  axilte  and  groins.  Nine  months  ago  lumps  were  noticed  in  the 
abdomen.  Three  weeks  ago  the  belly  and  legs  began  to  swell,  and  a 
week  ago  he  was  tapped  in  the  Out-patient  Department  and  2200  c.c. 
removed;  specific  gravity,  loii;  sediment  lymphocytic.  Eighteen 
months  ago  he  weighed  180  pounds;  a  month  ago,  160  pounds.  A 
gland  was  removed  in  the  Out-patient  Department,  and  a  diagnosis  of 
lymphosarcoma  or  lymphoblastoma  (Mallory)  made. 

On  physical  examination  there  was  a  mass  of  glands,  roughly 
10  by  8  cm.,  in  the  left  side  of  the  neck,  not  adherent  to  the  skin,  and 
fairly  movable.  Elsewhere  in  the  neck,  axillae,  and  groins  there  were 
glands  from  the  size  of  a  bean  to  that  of  a  hickory  nut.  The  right 
pupil  slightly  larger  than  the  left.  Heart's  apex,  1.5  cm.  outside  the 
nipple  line.  Cardiac  examination  otherwise  not  significant;  lungs 
negative.  The  abdomen  showed  evidences  of  free  fluid  and  large  ir- 
regular tumors.  The  spleen  and  fiver  not  made  out.  On  the  posterior 
rectal  wall  a  mass  half  the  size  of  the  fist,  hard  and  nodular,  was 
palpable. 

He  was  tapped  on  November  25  th  and  82  ounces  of  brownish-red 
fluid  obtained.  On  December  4th,  86  ounces  more  were  removed. 
Specific  gravity,  1015;  sediment  mostly  epithelial  cells.  December 
8th,  115  ounces  more  were  withdrawn.  December  20th,  only  12 
ounces.  December  24th,  17  ounces  more.  December  28th,  :j;-rays 
showed  a  shadow  over  the  whole  left  side  of  the  chest. 

Outcome. — Under  diuretin,  started  December  26th,  urine  rose  on 
the  30th  to  62  ounces,  and  several  times  subsequently  60  to  80  ounces 
were  obtained  as  the  result  of  diuretin.     He  was  tapped  December  28th 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  685 

and  7  pints  obtained.  On  January  3d,  50  ounces;  January  9th,  6 
pints;  January  15th,  106  ounces;  January  19th,  96  ounces.  He  left 
the  hospital  January  21st,  and  died  soon  after  at  home. 

Case  309 

A  stage-manager  of  thirty-one  entered  the  hospital  June  29,  1907. 
The  patient  has  been  well,  so  far  as  he  knows,  until  three  and  one-half 
weeks  ago,  when  he  began  to  feel  rather  poorly,  and  three  weeks  ago 
gave  up  work  on  account  of  spells  of  colicky  pain  in  the  abdomen,  espe- 
cially after  a  heavy  meal.  The  pain  always  shifted  from  one  point  to 
another  in  the  abdomen  and  was  not  accompanied  by  any  tenderness. 
The  attacks  lasted  two  or  three  days,  with  intervals  of  entire  comfort 
between  times,  during  which  intervals,  however,  he  has  felt  weak, 
feverish,  thirsty,  and  has  been  unable  to  take  solid  food. 

Six  days  ago  he  felt  fine  and  went  on  a  visit  to  Lexington,  where  he 
ate  ice-cream  and  cake  and  took  two  glasses  of  champagne.  That 
night  he  had  chills,  fever,  and  nausea.  The  next  morning  he  was  weak 
and  had  headache,  but  went  to  work  and  kept  at  it  through  the  day. 
That  night  he  had  epigastric  pain  and  vomiting,  and  has  since  then 
remained  in  bed,  feverish  and  sleepless.  Three  days  ago  the  abdomen 
swelled  and  became  generally  sore.  For  twenty-four  hours  he  has 
had  much  hiccup  and  belching  of  gas. 

On  physical  examination  the  patient  is  mentally  alert,  but  looks 
very  sick.  The  head,  chest,  and  extremities  are  negative.  The  abdo- 
men is  distended,  the  navel  flushed,  general  tenderness  throughout, 
marked  in  the  epigastrium,  but  not  in  the  right  iliac  region.  Shifting 
dulness  in  the  flanks.  Spleen  enlarged  on  percussion.  One  typical 
rose  spot  on  the  back.  The  white  cells  are  10,800;  hemoglobin,  80  per 
•cent.;  Widal  reaction  negative.  The  temperature  is  101°  F.;  pulse, 
100.  The  urine  is  35  ounces  in  twenty-four  hours;  specific  gravity, 
1030;  slightest  possible  trace  of  albumin;  rare  granular  cast.  The 
vomitus  consists  of  greenish  fluid,  mucus  and  undigested  food.  Guaiac 
always  negative.    HCl  absent. 

Discussion. — Three  weeks'  colic  with  fever  in  attacks  lasting  two  or 
three  days  at  a  time,  then  three  days  of  a  sore  and  swollen  belly,  fol- 
lowed by  twenty-four  hours  of  hiccuping,  leads  us  straight  to  the  diag- 
nosis of  general  peritonitis,  dependent  upon  some  focus  of  inflamma- 
tion within  the  abdomen.  The  physical  examination  shows  evidence 
of  free  fluid  and  of  general  tenderness,  such  as  is  produced  by  perito- 
nitis. The  amount  of  fever  and  leukocytosis  is  not  great,  and  must 
be  accounted  for,  if  we  stick  to  the  theory  of  peritonitis,  by  saying 


686  DIFFERENTLA.L  DIAGNOSIS 

that  the  patient  is  overwhelmed  by  his  infection  and  cannot  react 
against  it. 

Is  the  spleen  enlarged?  I  see  no  evidence  of  it.  A  spleen  that  we 
cannot  feel  should  never  be  considered  enlarged,  no  matter  what  the 
percussion  outlines  are.  This  is  not  to  say  that  such  enlargement  can- 
not exist,  but  only  that  we  cannot  feel  sure  of  it,  and  that  an  enlarged 
area  of  dulness  in  the  splenic  region  frequently  exists  without  any 
enlargement  of  the  spleen  or  any  other  local  cause  of  importance. 

Among  the  diagnoses  likely  to  be  made  in  this  case  we  will  take  first 
the  inevitable  ptomain-poisoning.  Any  abdominal  pain  which  the 
patient  connects  with  a  supposedly  poisonous  material  is  very  apt  to 
be  called  ptomain-poisoning  by  the  patient  himself  and  by  his  doctor. 
Such  a  diagnosis  has  an  impressive  sound  and  pleases  the  patient,  yet 
it  is  almost  inevitably  a  blunder.  True  food-poisoning  is  rare,  and, 
even  if  poisons  from  food  are  actually  the  cause  of  the  patient's  troubles, 
we  have  no  reason  to  assume  that  these  poisons  are  really  ptomains. 
In  the  vast  majority  of  cases,  the  term  "ptomain-poisoning"  is  only  a 
blind  to  cover  up  our  ignorance  of  what  the  actual  diagnosis  is.  Within 
the  past  year  or  two  I  have  known  the  following  diseases  miscalled 
ptomain-poisoning:  tabes  dorsahs  with  gastric  crisis,  lead-poisoning, 
appendicitis,  gall-stones,  cancer  of  the  colon,  and  uremia.  Without 
much  trouble  the  hst  might  be  greatly  extended. 

The  commonest  cause  of  an  otherwise  general  peritonitis  is  inflam- 
mation of  the  appendix.  I  cannot  rule  out  this  diagnosis  here,  but 
there  are  no  local  physical  signs  to  support  it. 

Some  cases  of  tuberculous  peritonitis  remain  entirely  latent  for  a 
long  time  and  then  suddenly  manifest  themselves  by  acute  symptoms, 
due  to  local  peritonitis  or  obstruction  by  adhesions.  The  presence  of 
shifting  dulness  in  the  flanks  might  be  interpreted  as  supporting  this 
conjecture.  As  a  rule,  however,  the  patient  is  not  nearly  as  sick  as  this 
patient  seems  to  be.  In  the  acute  complications  of  tuberculous  peri- 
tonitis, the  general  condition  of  the  patient  remains  surprisingly  good. 
Such  a  feature  as  a  twenty-four-hour  hiccup  would  not  be  expected. 

Acute  intestinal  obstruction  of  unknown  origin  might  produce  all 
the  symptoms  here  described.  At  this  patient's  age,  however,  intes- 
tinal obstruction  is  rare,  unless  there  has  been  a  previous  peritonitis 
or  laparotomy. 

Acute  gall-bladder  disease  is  certainly  a  possibility,  although  we 
have  no  jaundice,  no  demonstrable  enlargement  of  the  gall-bladder, 
and  no  local  tenderness.  Had  the  gall-bladder  actually  perforated, 
the  patient's  condition  would  be  even  more  grave  than  it  is.     The 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  687 

shifting  of  the  coHcky  pain  from  point  to  point  is  not  what  one  expects 
in  gall-bladder  disease. 

Peptic  ulcer  usually  shows  a  longer  history  of  gastric  symptoms 
and  less  shifting  colic.  Nevertheless,  it  is  impossible  to  exclude  a 
perforation  of  such  an  ulcer  with  general  peritonitis  as  a  result. 

On  the  whole,  then,  I  am  unable  to  reach  a  definite  diagnosis  of  the 
cause  of  this  patient's  general  peritonitis.  Intestinal  obstruction 
seems  as  probable  as  anything,  with  appendicitis  a  close  second. 

Outcome.— Operation,  July  2d,  showed  2  quarts  of  clear  fluid  in 
the  abdomen,  the  small  intestine  greatly  distended,  no  cause  for  ob- 
struction found.  Incision  was  then  enlarged  downward  and  a  coil 
of  intestine,  apparently  from  the  upper  ileum,  found  thickened,  blue, 
and  covered  with  a  fibrous  exudate.  The  mesentery  corresponding 
with  this  loop  was  thick  and  porky.  Above  this  point  the  intestine 
was  distended;  below  it,  contracted.  The  diseased  loop  was  clamped 
and  cut  away.  The  patient  died  the  next  day.  Autopsy  showed 
chronic  appendicitis  with  abscess  formation;  suppurative  thrombosis 
of  the  portal  vein,  inferior  and  superior  mesenteric  veins  and  their 
radicles;  general  peritonitis. 

Case  310 

A  rubber  worker  of  forty-nine,  born  in  Austria,  entered  the  hospital 
January  26,  1910.  The  patient  has  noticed  enlargement  of  the  ab- 
domen for  five  weeks;  previously  to  that  he  has  been  well.  His  father 
died  of  lung  trouble  at  fifty-four.  He  had  three  brothers  and  one  sister 
who  died  of  unknown  cause.  One  living  brother  has  stomach  trouble. 
The  patient's  wife  and  nine  children  are  well.  He  drinks  half  a  pint  of 
whisky  a  day.  He  has  done  this  for  thirty-five  years,  with  a  Httle 
beer  and  wine  occasionally.  He  spends  thirty-five  cents  a  week  for 
tobacco. 

Abdominal  swelling  compelled  him  a  month  ago  to  give  up  work, 
though  he  has  no  considerable  pain  and  rarely  vomits.  At  the  same 
time  his  skin  became  yellow,  his  stools  light  colored,  his  urine  dark, 
his  feet  swelled,  and  a  cough  appeared,  which  has  since  become  worse. 
Appetite  and  sleep  are  good,  and,  so  far  as  he  knows,  he  has  lost  no 
weight. 

Physical  examination  showed  fair  nutrition  and  was  generally 
negative,  except  as  relates  to  the  abdomen,  the  general  yeUow  discolor- 
ations  of  skin  and  mucous  membranes,  and  the  absence  of  knee-jerks. 
The  abdomen  showed  shifting  dulness  in  the  flanks  and  elsewhere, 
except  for  a  small  area  of  tympany  about  the  navel.     No  tenderness  or 


688  DIFFERENTLA.L   DIAGNOSIS 

masses  could  be  detected.  The  knee-jerks  were  not  obtained.  Plantar 
reflexes  normal.  Save  for  the  presence  of  bile  the  urine  showed  noth- 
ing remarkable  and  the  blood  was  normal.  The  evening  temperature 
ranged  in  the  neighborhood  of  ioo°  F.  during  two  weeks'  observation. 
The  temperature  was  usually  normal  in  the  morning.  The  stools 
were  of  normal  color  and  contained  bile.  They  were  negative  to 
guaiac  and  showed  no  special  abnormalities. 

Two  and  one-half  quarts  of  fluid  were  removed  from  the  abdomen 
on  the  29th.  After  tapping  the  surface  of  the  liver  it  seemed  coarsely 
nodular.  The  abdominal  fluid  had  a  gravity  of  1008,  contained  i 
per  cent,  albumin,  and  a  sediment  with  88  per  cent,  of  small  lympho- 
cytes. 

Discussion. — Lead-poisoning,  which  is  brought  to  our  attention  by 
this  patient's  occupation  (since  litharge  is  used  in  the  manufacture  of 
rubber),  does  not  ordinarily  produce  abdominal  enlargement  as  the 
most  noticeable  symptom,  and  without  pain.  The  abdominal  enlarge- 
ment which  we  sometimes  see  in  lead-poisoning  is  due  to  gas  and  is 
associated  with  pain  and  constipation.  If  this  patient  has  plumbism, 
his  abdominal  symptoms  are  not  at  all  characteristic  of  it. 

The  family  history  of  tuberculosis  leads  us  to  speculate  on  the 
possibility  of  tuberculous  peritonitis,  which  might  quite  possibly  come 
on  in  this  way,  though  rarely  in  a  patient  of  forty-nine.  The  presence 
of  jaundice,  absent  knee-jerks,  and  swelled  feet  cannot  be  easily  ac- 
counted for  in  this  way,  and  the  cough  is  much  more  likely  to  be  due  to 
a  high  diaphragm  than  to  tuberculosis.  On  the  other  hand,  tubercu- 
losis would  easily  account  for  the  condition  of  the  abdomen  and  for  the 
fever. 

The  alcoholic  history  leads  straight  to  cirrhosis  of  the  liver  as  a 
plausible  explanation  of  his  symptoms.  I  see  nothing  in  the  case  to 
exclude  this  diagnosis,  though  fever  is  not  the  rule  in  cirrhosis,  and  we 
cannot  thus  account  for  the  loss  of  knee-jerks.  Moreover,  the  small 
nodules  of  the  cirrhotic  liver  surface  are  rarely,  if  ever,  palpable 
through  the  belly  wall. 

If,  however,  we  suppose  a  cirrhosis  of  the  syphilitic  type,  we  can 
explain  the  loss  of  knee-jerks  as  manifestations  of  the  same  infection. 
The  acetic  fluid  obtained  by  tapping  has  the  characteristics  usually 
seen  in  cirrhosis,  whether  of  the  alcoholic  or  syphihtic  type,  and  its 
low  specific  gravity  militates  against  a  diagnosis  of  cancerous  perito- 
nitis or  tuberculosis. 

Syphilis  is  the  best  working  hypothesis. 

Outcome. — Vigorous  antisyphiltic  treatment  caused  no  improve- 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  689 

merit.  On  the  5th  of  February  he  had  to  be  tapped  again,  and  about 
the  same  amount  of  fluid  of  the  same  character  was  withdrawn.  This 
had  to  be  repeated  once  more  on  the  9th  of  February,  when  3  quarts 
were  withdrawn.  The  tube  of  the  trocar,  when  moved  about,  seemed 
to  encounter  either  adhesions  or  glands,  and  the  fluid  did  not  seem  to  be 
entirely  free  in  the  abdominal  cavity.  The  patient  went  home  on  the 
loth,  and  died  March  17,  19 10. 

Case  311 

A  laborer  of  twenty-eight  entered  the  hospital  April  i,  1910.  The 
patient  comes  to  the  hospital  because,  as  he  says,  his  stomach  has  been 
markedly  enlarged  for  the  past  two  weeks.  This  has  been  accom- 
panied by  considerable  pain,  which  compelled  him  to  give  up  work 
three  weeks  ago.  Later,  he  remembered  that  fluid  had  been  removed 
from  his  left  chest  five  months  previously.  Nevertheless,  he  had  been 
steadily  at  work  since  that  time  until  the  present  illness.  His  family 
history,  past  history,  and  habits  are  excellent.  He  thinks  he  has  lost 
some  v/eight  and  strength,  and  his  appetite  has  been  poor.  He  has  a 
slight  cough,  with  yellowish  sputum.  He  entered  the  hospital  with  a 
diagnosis  of  ''cancer  of  the  stomach." 

Physical  examination  showed  a  sallow,  pale  skin,  although  the 
blood-smear  showed  only  slight  achromia;  hemoglobin,  75  per  cent. 
There  was  harsh  breathing  at  the  left  apex,  otherwise  no  pulmonary 
lesions,  save  such  as  could  be  explained  by  the  abdominal  enlargement. 
There  was  shifting  dulness  in  the  flanks,  with  tympany  in  the  distended 
region  about  the  navel.  The  spleen  was  not  felt;  the  abdomen  and 
extremities  wholly  negative.  The  blood  and  urine  were  negative,  the 
temperature  slightly  elevated  at  night  during  the  first  ten  days  of 
his  stay  in  the  hospital,  usually  reaching  99.5°  to  100°  F.  After  that  it 
did  not  go  above  99°  F.  during  a  month's  observation.  The  sputum, 
four  times  examined,  showed  nothing  of  interest.  His  abdomen  re- 
mained always  distended  with  gas,  even  when  fluid  could  no  longer  be 
demonstrated  there.  Enemata  had  no  considerable  effect  on  this  gas. 
The  skin  tuberculin  test  was  slightly  positive.  There  was  always 
dulness  and  diminished  respiration  at  the  bases  of  the  lungs,  sometimes 
with  fine  crackles,  but  the  high  position  of  the  diaphragm  made  it  diffi- 
cult to  be  sure  that  any  independent  disease  existed  in  the  pleural 
cavity. 

Discussion. — When  we  know  that  fluid  has  been  recently  removed 
from  the  chest  of  a  patient  free  from  cardiac  and  renal  disease,  we  can 
have  little  doubt  that  he  has  had  pleurisy;  that  is,  a  tuberculosis.     Any 

Vol.  11—44 


690  DIFFERENTIAL  DIAGNOSIS 

other  symptoms  which  may  appear  will,  therefore,  be  naturally  inter- 
preted in  the  light  of  this  earUer  disease. 

When  a  patient  with  such  a  history  shows  fluid  in  the  abdomen, 
with  anemia,  slight  fever,  and  questionable  signs  at  the  apex  of  the  left 
lung,  tuberculous  peritonitis  is  by  far  the  most  probable  diagnosis. 
The  diagnosis  could  be  further  supported  were  the  abdomen  to  be 
tapped  and  a  high-gravity  fluid  obtained.  This  would  help  us  to 
exclude  cirrhosis  and  syphilis  of  the  liver. 

Mahgnant  disease  as  a  cause  of  ascites  should  always  be  remembered 
in  a  case  of  this  kind,  although  we  cannot  take  the  idea  very  seriously 
in  view  of  the  patient's  age,  his  lack  of  stomach  or  bowel  symptoms, 
and  the  absence  of  any  palpable  tumor. 

A  point  of  interest  in  this  case  is  the  very  marked  gaseous  disten- 
tion which  persisted  after  the  evidences  of  fluid  had  disappeared.  It 
should  always  be  remembered  that  in  cases  of  ascites,  from  any  cause, 
gaseous  distention  of  the  intestinal  coils  is  for  some  reason  or  other  a 
very  frequent  concomitant.  At  times  it  is  so  extreme  as  to  mask  the 
existence  of  fluid  beneath  or  behind  it.  Sometimes  the  obvious  gaseous 
distention  weighs  far  too  strongly  in  our  minds  and  leads  us  to  sup- 
pose that  if  there  is  so  much  gas,  no  disease-producing  ascites  is  likely 
to  be  present.  But  the  truth  is  just  the  opposite.  A  belly  which  is 
chronically  and  obstinately  distended  with  gas  should  be  especially 
suspected  of  containing  free  fluid  as  well. 

Outcome. — By  the  27th  he  was  up  and  about  the  ward  and  seemed 
quite  strong,  though  his  abdomen  was  still  distended  with  gas  and  his 
bowels  difficult  to  move.  His  weight  had  risen  from  122  to  127I. 
pounds.     He  left  the  hospital  April  30,  1910. 

February  12,  19 11,  his  physician  reports  that  he  has  been  at  work 
and  had  a  splendid  appetite  until  February  nth,  although  for  two 
weeks  he  has  had  a  cough  and  night-sweats.  The  sputa  showed  many 
tubercle  bacilli.  The  belly  was  tense,  tympanitic,  and  showed  no  evi- 
dence of  fluid.  Weight,  1 25I  pounds.  Both  lungs  showed  coarse  moist 
rales. 

Case  312 

A  salesman  of  thirty-five  entered  the  hospital  May  9,  1910.  His 
family  history  was  unimportant.  The  patient  had  measles,  whooping- 
cough,  scarlet  fever,  and  diphtheria  when  young,  also  several  mild 
attacks  of  "inflammatory  rheumatism,"  but  has  never  been  laid  up. 
Eleven  years  ago  he  had  typhoid  fever  and  was  sick  four  weeks.  He 
has  had  occasional  sore  throats  and  one  attack  of  influenza.     He  has 


ASCITES   AND   ABDOMINAL  ENLARGEMENT  69 1 

been  said  to  have  a  weak  spot  in  one  lung,  and  two  years  ago  was  sent 
to  Saranac  Lake  by  Dr.  E.  G.  Janeway.  He  was  treated  there  for 
several  months  for  tuberculosis.  Since  then  he  has  worked  each  winter 
and  rested  each  summer.  He  denies  venereal  disease  and  takes  no 
alcohol,  but  until  of  late  has  smoked  thirty  to  forty  cigarettes  daily. 

He  has  been  able  to  attend  to  business  up  to  January,  1910,  when 
his  stomach  began  to  trouble  him,  distress  after  eating,  abdominal 
distention,  gas,  and  abdominal  pain  being  the  principal  troubles.  His 
habitual  cough  has  become  more  severe,  though  it  is  still  dry.  In  con- 
nection with  his  gastric  distress  he  has  times  of  what  he  calls  being 
"choked  up,"  when  he  vomits  and  gets  very  short  of  breath.  In 
February  he  was  in  a  hospital  in  California  for  seven  weeks,  and  was 
treated  for  stomach  trouble  without  rehef .  For  the  past  two  months 
his  feet  have  been  swollen  at  night  and  his  eyesight  has  been  getting 
poor.  In  spite  of  all  these  troubles,  his  appetite  has  been  good  and  his 
bowels  have  moved  daily.  His  sleep  has  been  disturbed  by  severe  gen- 
eralized headache.  He  passes  urine  twice  or  thrice  at  night.  He  has 
lost  24  pounds  in  two  years  and  now  weighs  1 10  pounds. 

Physical  examination  showed  a  well-nourished  man,  pupils  and 
reflexes  normal,  glands  the  size  of  beans  in  the  neck,  axillae,  and  groins. 
Heart's  impulse  in  the  nipple  line,  fifth  space,  no  enlargement  to  the 
right.  The  aortic  second  sound  slightly  accentuated.  No  murmur. 
Blood-pressure,  225  mm.  Hg.,  systolic.  Lungs  hyperresonant  with 
squeaks  scattered  throughout.  At  the  right  base,  dulness  with  feeble 
breathing  and  distant  voice  sounds.  Abdomen  full,  t5niipanitic 
throughout,  and  slightly  tender.  The  liver  dulness  extended  almost  to 
the  navel,  but  the  edge  of  the  organ  was  not  felt  and  the  abdomen  was 
otherwise  negative.  The  fundus  oculi  showed  great  indistinctness  at 
the  edges  of  the  disk,  but  numerous  large  hemorrhages  and  patches  of 
exudate  throughout.  Throughout  most  of  the  patient's  six  months' 
stay  in  the  hospital  the  urine  averaged  45  ounces  in  twenty-four  hours, 
with  a  specific  gravity  from  1006  to  1014  and  albumin  from  a  slight 
trace  to  0.7  per  cent.;  sediment  a  rare  hyaline  cast,  sometimes  with  a 
few  cells  or  fat  drops  adherent.  Leukocytes  14,000,  87  per  cent,  of 
which  were  polynuclear;  hemoglobin,  90  per  cent. 

At  entrance  the  patient  seemed  perfectly  comfortable,  except  for 
a  respiration  of  37  and  considerable  headache.  About  7  p.  m.  he  began 
to  vomit,  his  respirations  increased,  and  he  became  very  nervous.  A 
hot  tub  bath  with  a  hot  pack  was  given,  but  the  exertion  was  too  much 
for  the  patient  and  he  had  terrible  dyspnea,  though  the  sweating  after 
the  bath  was  satisfactorily  profuse.     With  morphin  he  had  a '-fair 


692  DIFFERENTIAL   DIAGNOSIS     • 

night,  but  early  the  next  morning  he  had  an  agonizing  headache,  per- 
sistent vomiting,  and  Cheyne-Stokes  breathing,  with  shght  generalized 
spasms  during  the  period  of  apnea.  Accordingly,  15  ounces  of  blood 
were  withdrawn  and  i  pint  of  salt  solution  given  under  the  skin.  The 
systolic  blood-pressure  fell  55  points,  but  soon  regained  its  former  high 
level.  The  patient  was  somewhat  relieved,  and  thereafter  improved 
under  daily  hot-air  baths  with  pilocarpin.  Although  the  headache 
persisted  and  he  rejected  almost  all  food,  he  had  no  real  convulsion. 

On  the  12th  dyspnea  was  still  troublesome  and  he  complained  of 
faintness.  There  was  marked  reduplication  of  the  second  sound  in 
the  third  left  interspace  and  an  occasional  premature  beat.  Systolic 
blood-pressure,  215.  There  were  no  rales  in  the  lungs  and  no  edema. 
Twenty-four  ounces  of  normal  saline  solution  were  given  under  the 
skin  and  no  rise  of  blood-pressure  followed.  At  this  time  the  left 
border  of  cardiac  dulness  was  14  cm.  from  the  median  line.  On  the 
14th,  headache  and  vomiting  continuing,  12  ounces  of  blood  were  with- 
drawn and  I  pint  of  saline  solution  injected.  He  was  then  given  ^  gr. 
of  cocain  by  mouth  and  a  little  food.  He  retained  this,  fell  asleep,  and 
next  morning  seemed  much  better.  Thereafter  he  steadily  improved, 
and  by  the  21st  his  dyspnea  was  gone.  He  then  took  food  regularly 
(though  in  small  quantities)  and  slept  fairly.  His  headache  still  per- 
sisted and  he  occasionally  vomited.  Various  diuretics,  such  as  sodium 
theocin  acetate,  were  given  without  relief.  Aspirin,  10  gr.,  every  hour 
for  three  days,  gave  some  relief  to  headache,  but  |  to  |  gr.  of  morphin 
was  needed  almost  daily  to  control  headache. 

On  the  31st  of  May  he  was  doing  very  well,  at  times  quite  free  from 
headache.  There  had  been  no  return  of  edema  or  convulsive  move- 
ments. Hot-air  baths  without  pilocarpin  did  not  seem  to  act  favorably. 
Blood-pressure  gradually  declined  to  the  neighborhood  of  150,  where  it 
persisted  until  the  second  week  in  June ;  then  it  ranged  at  1 70  for  two 
weeks.  Any  attempts  to  sit  up  straight,  to  stop  the  hot-air  baths,  or  to 
bear  any  excitement  produced  vomiting  and  headache  at  once.  June 
9th  he  could  read  a  postal  card,  though  at  entrance  he  could  scarcely 
see  people  about  his  bed.  It  was  found  an  advantage  to  add  lactose  to 
his  liquid  food  in  order  to  increase  its  value.  After  the  20th  of  June 
his  blood-pressure  ranged  for  a  month  in  the  neighborhood  of  200,  but 
despite  this  he  improved  steadily  and  by  the  middle  of  July  was  in 
better  condition  than  at  any  time.  He  was  able  to  sit  up  in  bed,  to 
read  to  himself,  and  he  hardly  seemed  like  the  same  patient.  The  eye 
fundus,  however,  showed  no  notable  change. 

On  the  1 8th  of  July  he  was  able  to  sit  up  in  a  chair  without  headache 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  693 

or  any  other  ill  effects  and  was  eating  ordinary  meals  without  distress. 
The  blood-pressure  meantime  was  ranging  higher  than  at  any  time, 
230  to  250.  July  19th  he  could  stand  alone,  though  he  could  not  walk. 
His  abdomen  was  always  markedly  prominent,  but  showed  no  evident 
fluid,  and  his  lungs  were  clear.  Shortly  after  this  he  became  more  un- 
comfortable. During  the  early  part  of  August  all  his  bad  symptoms 
returned,  and  on  the  12th  of  August  the  slightest  noise  caused  twitching. 
Thereafter  his  blood-pressure  ranged  a  little  lower,  in  the  neighborhood 
of  200  for  the  next  month,  but  the  urinary  output  increased  and  the 
pulse  somewhat  improved.  About  the  i6th  of  August  a  harsh  systolic 
murmur  developed,  loudest  in  the  pulmonary  area,  but  audible  over  the 
whole  precordia.  The  pulmonic  second  sound  was  now  greater  than 
the  aortic  second,  the  latter  sharp  but  distant.  Rales  appeared  in  the 
lungs  and  edema  over  the  sacrum.  One-eighth  grain  of  morphin  with 
2^0  gr.  of  cocain  gave  him  good  nights,  but  he  began  at  this  time  to  be 
incontinent.  His  headaches  were  more  or  less  reHeved  by  the  doses  of 
aspirin,  previously  mentioned. 

On  the  24th  of  August  he  was  almost  unconscious.  His  tempera- 
ture remained  elevated  for  several  days  without  obvious  cause.  On 
the  26th  the  left  border  of  cardiac  dulness  was  15  cm.  from  the  median 
line;  the  second  sound  to  the  left  of  the  sternum  was  very  loud,  and  a 
systolic  murmur  replaced  the  first  sound  all  over  the  precordia. 
Sloughing  hemorrhoids  were  discovered  at  this  time  and  may  have 
accounted  for  the  temperature.  At  this  time  the  blood-pressure  came 
down  to  160  for  a  few  days,  but  soon  rose  again,  and  on  the  14th  of 
September  was  220.  He  lost  flesh  steadily  at  this  time,  though  he  was 
able  to  eat  fairly  well,  and  his  heart  remained  strong.  Mentally  he 
was  very  dull.  After  the  7th  of  September  he  had  a  good  deal  of 
mild  delirium,  chiefly  of  a  happy  tjrpe. 

On  the  20th  he  was  a  living  skeleton,  with  a  large  heart  beating 
tirelessly  and  no  evidence  of  cardiac  failure.  Two  small  bed-sores 
developed  at  this  time.  He  still  ate  and  slept  well.  September  2  2d 
he  became  worse  and  passed  almost  no  urine  for  forty-eight  hours. 
The  blood-pressure  was  now  150,  having  been  dropping  steadily  since 
the  14th;  pulse  very  slow,  45  to  60,  regular.  There  was  no  marked 
edema  of  the  legs.  The  steady  decline  of  temperature,  pulse,  and 
blood-pressure  during  the  last  two  weeks  of  his  Hfe  is  shown  in  Fig. 
250.    He  died  on  the  27th. 

Discussion. — A  very  important  group  of  symptoms  points  straight 
toward  the  diagnosis  of  tuberculosis  in  this  case;  we  have,  first  of  all, 
the  dictum  of  an  almost  infalhble  diagnostician,  then  the  habitual 


694 


DIFFERENTIAL  DIAGNOSIS 


dry  cough,  the  dyspeptic  s}Tiiptoms,  and  the  sHght  glandular  enlarge- 
ment. There  is  another  point  favoring  tuberculosis,  viz.,  that  the 
patient  has  many  symptoms  in  many  places,  so  that  we  must  look  for 
some  disease  capable  of  attacking  many  organs  simultaneously.  Such 
diseases  are  especially  tuberculosis,  syphilis,  streptococcic  sepsis,  and 
the  malignant  neoplasms. 

But  there  is  a  second  group  of  symptoms  not  easily  explained  as 
part  of  a  tuberculous  process.     The  dyspneic  attacks,  the  swollen  feet, 

the  headaches  with  poor  sight, 
and,  above  all,  the  high  blood- 
pressure,  retinitis,  Cheyne-Stokes' 
breathing,  and  convulsions,  make 
it  almost  certain  that  we  are  deal- 
ing with  a  chronic  nephritis,  and 
at  this  patient's  age,  in  all  proba- 
bility, a  chronic  glomerular  neph- 
ritis. Amyloid  disease  of  the 
kidney,  such  as  might  be  second- 
ary to  tuberculosis,  would  not  be 
at  all  likely  to  give  us  such  a 
group  of  symptoms  as  this.  The 
striking  thing  about  amyloid  dis- 
ease, as  a  rule,  is  its  latency, 
its  colorless,  often  symptomless, 
course. 

Is  there  anything  in  the  case 
not  to  be  explained  by  glomerular 
nephritis?     I  see  nothing.     Syph- 
ilis and  malignant  disease,  which 
I  mentioned  in  former  paragraphs,  cannot  of  themselves  produce  any 
such  clinical  picture,  although  it  is,  of  course,  possible  that  the  neph- 
ritis may  have  been  of  syphilitic  origin. 

Outcome. — Autopsy  showed  chronic  glomerulonephritis,  arterio- 
sclerosis, hypertrophy  and  dilatation  of  the  heart,  myomalacia  of  the 
heart's  wall  near  the  apex,  with  mural  thrombi  in  this  region  and  each 
side  of  the  septum.  Also  thrombi  in  the  right  and  left  auricular  ap- 
pendages. There  were  infarcts  in  the  lower  lobes  of  the  lungs  and 
thromboses  of  small  branches  of  pulmonary  arteries;  acute  terminal 
pericarditis  and  pleuritis;  obsolete  tuberculosis  of  a  tracheal  lym- 
phatic gland;  small  papillary  adenoma  of  the  kidney.  The  absence 
of  any  considerable  evidence  of  tuberculosis  is  striking;  also  the  ab- 
sence of  any  infection  of  the  circulating  blood. 


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Fig.  250. — Blood-pressure  (starred  line), 
temperature,  pulse,  and  respiration  during 
the  last  two  weeks  of  life  in  Case  312. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT 


695 


Case  313 

A  housewife  of  forty-seven  entered  the  hospital  January  6,  191 1. 
The  patient  has  noticed  enlargement  of  the  abdomen  for  about  eight 
years.  At  first  it  was  larger  than  it  now  is.  The  present  size  has  been 
maintained  for  about  five  years.  Otherwise  she  has  always  been  well, 
though  formerly  subject  to  tonsilUtis  and  troubled  for  a  few  days,  eight 
years  ago,  by  an  attack  of  "malaria,"  in  Nashua,  N.  H.  She  was  in 
bed  four  days  with  chills  and  fever.  Family  history  and  habits  are 
excellent.     Menstrual  flow  has  been  excessive  for  seven  years,  and  she 


Fig.  251. — ^Position  and  size  of  mass  felt  in  Case  313. 


has  grown  increasingly  pale  and  weak  during  this  period.  She  worked 
until  to-day,  taking  care  of  her  house  and  doing  all  the  cooking  and 
sewing  for  her  husband  and  six  children,  but  not  washing.  Five 
months  ago  she  weighed  190  pounds;  a  week  ago,  176  pounds.  Her 
appetite  is  good,  bowels  costive,  urination  not  remarkable.  She  suffers 
no  pain  whatever. 

Physical  examination  showed  good  nutrition,  ivory-colored  skin, 
marked  pallor  of  the  mucous  membranes.  No  glandular  enlargement, 
pupils  and  reflexes  normal.     Chest  negative.     Abdomen  was  generally 


6g6  DIFFERENTIAL  DIAGNOSIS 

enlarged;  also  a  mass  as  in  Fig.  251.  The  mass  there  shown  filled 
two-thirds  of  the  abdomen,  was  firm,  freely  movable,  elastic,  and  not 
tender.  Otherwise  the  abdomen  was  not  remarkable.  There  was  con- 
siderable edema  of  both  legs  and  marked  varicose  veins  in  the  same 
area.  At  entrance  red  cells  numbered  1,900,000;  white  cells,  5000; 
hemoglobin,  25  per  cent.  The  stained  smear  showed  marked  achromia, 
with  considerable  variations  in  size  and  shape,  no  abnormal  staining 
reaction  or  nucleated  cells.  Blood-platelets,  160,000.  In  twenty  days 
the  red  cells  rose  to  4,500,000,  hemoglobin  to  70  per  cent.,  white  cor- 
puscles to  8000.  The  urine  averaged  45  ounces  in  twenty-four  hours, 
with  a  specific  gravity  of  1015,  a  trace  of  albumin,  and  no  casts. 
Systolic  blood-pressure,  125.  Feces  normal.  During  this  time  she 
took  Blaud's  mass,  20  gr.,  three  times  a  day.  After  the  first  two  days 
there  was  no  flowing.  Vaginal  examination  showed  her  cervix  high  in 
the  median  line  behind  the  pubes,  but  continuous  with  the  abdominal 
tumor.  The  diagnosis  in  the  medical  wards  was  in  doubt  as  between 
ovarian  cyst  and  uterine  fibroid.  Dr.  W.  J.  Mayo  saw  the  patient 
and  considered  it  fibroid.     Dr.  Farrar  Cobb  made  the  same  diagnosis. 

Discussion. — There  are  not  many  causes  for  an  abdominal  enlarge- 
ment lasting  eight  years  in  a  woman  of  forty-seven.  Aside  from  obesity 
and  gaseous  distention,  there  is  hardly  anything  but  uterine  fibroid 
and  ovarian  tumor.  The  fact  that  she  has  been  steadily  and  vigor- 
ously at  work,  and  that  she  is  still  well-nourished,  makes  any  malignant 
t3rpe  of  disease  improbable.  Between  fibroid  and  ovarian  cyst,  the 
amenorrhea  and  the  uterine  hemorrhages  strongly  favor  the  diagnosis 
of  fibroid.  The  elasticity  and  free  mobility  of  the  mass  is  slightly  in 
favor  of  cyst,  though  I  have  learned  to  distrust  all  inferences  based 
chiefly  upon  such  characteristics  of  a  pelvic  tumor.  The  position  of 
the  cervix  uteri  is  a  further  point  in  favor  of  fibroid. 

Outcome. — On  the  2d  of  February  the  abdomen  was  opened,  show- 
ing a  small  amount  of  free  fluid  and  a  tumor  of  soft  gelatinous  consist- 
ency, rather  tense,  but  showing  no  large  firm  parts  anywhere.  Hys- 
terectomy was  done.  Examination  of  the  growth  by  Dr.  W.  F.  Whit- 
ney showed  the  uterus  greatly  enlarged  by  a  single  growth  weighing 
4450  gm.  The  uterine  cavity  was  enlarged,  measuring  14  cm.  On 
section  the  growth  was  fasciculated,  its  meshes  being  filled  with  serous 
fluid.  These  meshes  were  shown  under  the  microscope  to  be  formed  of 
interlacing  bunches  of  fibrous  and  muscular  tissue.  Diagnosis,  fibro- 
myoma  with  lymphatic  dilatation,  so-called  cystic  fibroid.  The  patient 
made  an  excellent  recovery.  On  November  i,  191 2,  she  seemed 
entirely  well  and  had  gained  60  pounds. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  697 

Remarks.^ — That  a  patient  who  has  but  1,900,000  red  cells  should 
patiently  continue  to  do  the  whole  work  for  her  husband  and  six 
children  is  a  type  of  familiar  heroism  to  which,  despite  its  familiarity, 
I  cannot  forbear  to  allude. 

Case  314 

An  unoccupied  woman  of  thirty-five  entered  the  hospital  May  13, 
191 1.  The  patient  has  always  been  well,  though  she  had  scarlet  fever 
and  measles  as  a  child.  As  the  oldest  of  twelve  children  she  did  all  sorts 
of  work  until  ten  years  ago.  Then  she  had  a  sudden  swelling  of  the 
abdomen,  accompanied  by  severe  general  abdominal  pain,  which  con- 
fined her  to  bed  for  several  weeks.  She  had  no  vomiting,  but  has  never 
felt  really  well  since  that  time.  Any  excitement  or  strain  produces 
severe  headaches  and  general  aching  all  over  the  body.  She  passes  at 
times  large  quantities  of  very  pale  urine,  often  getting  up  five  to  ten 
times  at  night,  but  she  is  able  to  pass  it  only  when  she  is  calm.  Her 
bowels  always  move  with  difficulty,  and  there  is  a  dull  ache  in  that 
region  most  of  the  time.  Distention  of  the  abdomen  is  present  off  and 
on  in  varying  amounts.  It  is  always  greater  at  night  and  her  sleep  is 
very  poor.  For  a  year  she  has  had  a  sHght  cough  without  any  sputa. 
Moderate  exertion  makes  her  tired  and  short  of  breath,  but  she  has 
never  had  orthopnea  or  edema.  She  is  now  at  her  maximum  weight, 
no  pounds.  Appetite  is  fair,  but  she  has  little  ambition  for  food. 
Menstruation  is  regular,  but  scanty. 

Physical  examination  shows  good  nutrition,  normal  pupils  and 
reflexes,  no  glandular  enlargement,  chest  negative.  Abdomen  full  and 
very  prominent,  tympanitic  everywhere,  no  tenderness.  SHght  gen- 
eral rigidity.  Liver  and  spleen  apparently  not  enlarged.  Navel  not 
flushed.  A  slight  degree  of  ankle-clonus  on  each  side,  perhaps  vol- 
untary. Rectal  examination  negative.  Blood,  urine,  and  blood-press- 
ure normal.  No  temperature  in  one  week's  observation.  Calomel  and 
sodium  sulphate  produced  fourteen  movements  in  two  days,  but  the 
size  of  the  abdomen  did  not  change.  It  was  unaffected  by  turpentine 
stupes  or  by  the  rectal  tube.     On  the  19th  she  went  home. 

Discussion. — The  long  duration  of  this  case  is  its  most  interesting 
feature.  It  has  lasted  ten  years.  The  abdominal  enlargement  which 
she  now  complains  of  was  her  first  S3anptom  and  she  has  it  still.  She 
also  has  symptoms  in  various  other  parts  of  her  body  and  one  group 
of  urinary  s3miptoms  suggesting  the  vasomotor  instability  of  the  neu- 
rotic. The  anorexia,  insomnia,  and  headaches  from  any  strain  point 
in  the  same  direction. 


698  DIFFERENTIAL   DIAGNOSIS 

There  is,  however,  a  small  group  of  sjmiptoms  pointing  in  another 
direction ;  that  is,  her  year  of  slight  cough  with  dyspnea  and  distention 
of  the  abdomen,  which  might  mean  tuberculous  peritonitis,  especially 
as  physical  examination  shows  slight  general  rigidity,  the  precise  char- 
acteristic of  the  tuberculous  abdomen. 

Yet  the  other  and  larger  group  of  symptoms  is,  on  the  whole,  the 
more  important,  for  she  has  had  the  abdominal  trouble  throughout,  and 
it  is  exceedingly  improbable  that  tuberculous  peritonitis  should  last  ten 
years  without  producing  any  loss  of  weight.  The  fact  that  she  is  now 
at  her  maximum  weight  is  almost  sufficient  to  exclude  organic  disease. 

If,  then,  we  exclude  organic  disease,  can  a  neurosis  account  for  her 
abdominal  enlargement?  It  is  well  known  that  gaseous  distention 
often  accompanies  and  sometimes  conceals  ascites.  It  is,  therefore, 
conceivable  that  there  may  be  some  organic  trouble  in  the  background, 
but  we  can  only  say  that  we  have  done  our  best  to  find  such  and  failed. 

Outcome. — July  25,  19 14,  a  friend  of  the  patient  writes  that  since 
leaving  the  hospital  she  has  been  quite  well  when  quiet,  but  under  any 
mental  strain  or  worry  her  bowels  almost  immediately  become  dis- 
tended to  an  enormous  size,  causing  great  distress  and  pain  and  stop- 
ping the  action  of  the  bladder  and  bowels.  Rest  and  sleep  dispel  these 
symptoms,  but  anything  that  happens  out  of  the  ordinary,  causes  the 
abdomen  to  swell  up  almost  immediately.  She  is  physically  well  and 
contented. 

Case  315 

An  unoccupied  woman  of  fifty-eight  entered  the  hospital  October 
31,  191 1.  A  year  ago  the  patient  began  to  have  sharp  attacks  of  pain 
in  the  lower  abdominal  region,  rather  more  to  the  right.  The  pain  was 
not  definitely  related  to  the  taking  of  food.  At  the  same  time  the 
abdomen  became  somewhat  enlarged,  and  after  a  week  she  began  to 
vomit  frequently,  so  that  for  the  next  ten  days  she  kept  almost  no  food 
in  her  stomach.  After  that  she  was  better,  but  her  symptoms  have 
recurred  every  few  weeks,  lasting  from  three  to  seven  days.  For  six 
months  she  has  vomited  once  or  twice  almost  daily.  Her  pain  has 
become  more  frequent,  but  less  sharp.  The  abdominal  enlargement 
has  steadily  increased  during  the  last  six  months,  but  the  rest  of  her 
body,  she  thinks,  has  emaciated.  Her  legs  are  swollen  somewhat  in 
the  daytime,  but  not  more  than  they  have  always  been,  as  she  has 
always  had  varicose  veins.  She  has  tried  to  keep  at  work  during  the 
year,  but  has  often  had  to  give  up  for  days  or  weeks  and  for  the  last 
fortnight  has  done  nothing.  Her  bowels  often  do  not  move  for  three 
or  four  days.     She  has  no  jaundice. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  699 

Physical  examination  shows  marked  emaciation,  good  color,  pupils 
and  reflexes  normal,  no  glandular  enlargement.  Chest  negative. 
Abdomen  dome  shaped,  much  distended,  with  an  elastic  feel,  and  a 
marked  fluid  wave  transmitted  to  the  top  as  well  as  to  the  sides  of  the 
abdomen.  The  abdomen  does  not  sag  into  the  flanks;  it  is  everywhere 
dull  and  nowhere  tender.  Liver  and  spleen  are  not  felt.  The  legs 
show  slight  edema  and  marked  varicosity  of  the  veins.  The  cervix 
uteri  is  high,  not  otherwise  remarkable.  There  is  no  drag  upon  the 
cervix  when  the  abdomen  is  manipulated.  The  fundus  not  made  out. 
In  the  median  line,  just  below  the  navel,  is  a  hard,  smooth,  almost 
immovable  mass,  the  size  of  an  egg.  Blood  and  urine  normal.  No 
temperature  in  two  weeks'  observation.  Systolic  blood-pressure, 
156  mm.  Hg.;  diastoHc,  80  mm.  Hg.;  weight,  91  pounds. 

Discussion.— A  year  of  abdominal  symptoms  in  a  woman  of  fifty- 
eight,  previously  well,  are  always  ominous  symptoms.  One  always 
fears  malignant  disease,  especially  when,  as  in  this  patient,  there  has 
been  vomiting  and  swelling  of  the  legs.  The  latter  symptom,  how- 
ever, need  not  alarm  us,  as  it  is,  in  all  probability,  due  to  her  varicose 
veins  and  is  by  no  means  a  new  symptom. 

Much  more  serious  is  the  marked  emaciation,  as  shown  on  physical 
examination,  and  the  apparent  presence  of  an  ascites.  We  cannot  at- 
tribute such  an  ascites  to  the  heart  or  to  the  kidney.  It  is  not  likely 
to  be  of  Hver  origin  at  her  age  and  with  her  history.  It  does  not  pre- 
sent the  picture  of  tuberculous  peritonitis.  The  only  common  cause 
for  ascites  that  remains  is  tumor,  usually  a  malignant  tumor  in  some 
part  of  the  abdomen.  The  hard,  smooth  mass  below  the  umbihcus  is, 
in  all  probability,  part  of  such  a  tumor.  It  is  possible  that  the  ascites 
may  be  associated  with  a  benign  tumor,  such  as  an  ovarian  fibroma, 
ovarian  cystoma,  or  a  fibroid  uterus,  but  no  one  of  these  is  a  frequent 
cause  of  ascites.  On  the  whole,  we  have  reason  to  fear  malignant  dis- 
ease.    In  any  case  the  abdomen  must  be  opened. 

Outcome. — On  the  7th  of  November,  191 1,  an  ovarian  cyst  about 
15  inches  in  diameter  was  removed.  It  contained  about  6  quarts  of 
fluid  and  was  not  adherent.  It  apparently  originated  from  the  left 
ovary.  The  patient  did  well  after  operation,  and  December  3,  191 2, 
reported  at  the  hospital  in  perfect  condition. 

Remarks. — This  case  was  sent  to  the  hospital  as  one  of  ascites,  but 
this  diagnosis  was  never  seriously  considered.  The  shape  of  the  ab- 
dominal enlargement  was  wholly  unlike  ascites,  and  the  ordinary  causes 
of  ascites  could  with  reasonable  probability  be  excluded. 


700 


DIFFERENTIAL   DIAGNOSIS 


Case  316 

A  housewife  of  forty-eight,  born  in  Russia,  entered  the  hospital 
January  19,  191 2.  Ten  years  ago  the  patient  fell,  striking  her  right 
side.  Since  then  she  has  noticed  pain  in  the  right  flank  and  back, 
gradually  growing  more  severe.  For  five  weeks  she  has  noticed 
abdominal  enlargement,  and  her  sleep  has  been  disturbed  at  night  by 
the  pain  above  described.  For  a  month  her  urine  has  been  scanty 
and  painful  in  passing.  She  has  no  appetite  and  food  causes  discom- 
fort or  nausea.     At  the  onset  of  her  troubles  she  vomited  occasionally, 


Fig.  252. — Condition  of  abdomen  in  Case  316  on  January  19,  191 2. 


but  has  not  done  so  now  for  some  weeks.  She  has  been  in  bed  for  the 
past  month  on  account  of  pain  and  weakness.  She  thinks  she  has  lost 
flesh.     Three  days  ago  her  feet  became  swollen. 

Physical  examination  shows  much  emaciation.  Slight  general 
brownish  pigmentation  of  the  skin.  Pupils,  glands,  and  reflexes 
normal.  Chest  negative  save  for  moist  rales  at  the  right  base  behind. 
The  abdomen  was  greatly  enlarged  and  tense,  the  right  side  in  the  re- 
gion of  the  liver  especially  prominent.  In  the  right  flank  and  epigas- 
trium a  mass  can  easily  be  felt,  as  shown  in  Figs.  252-254.    Impulse 


ASCITES    AND    ABDOMINAL   ENLARGEMENT 


701 


exerted  upon  the  mass  in  front  is  plainly  transmitted  to  the  costover- 
tebral angle.  There  is  shifting  dulness  in  the  dependent  portions  of 
the  abdomen  and  tympany  about  the  navel.  Liver  dulness  reaches 
up  to  the  sixth  rib,  mammary  line.  Spleen  not  felt.  There  is  moder- 
ate soft  edema  of  the  feet  and  legs.  Wassermann  reaction  is  negative. 
Urine  negative.  Blood  showed  a  leukocytosis  varying  from  22,000  to 
24,500,  with  polynuclear  cells  greatly  in  excess.  No  temperature  in  a 
week's  observation.  Blood-pressure  normal.  By  tapping  the  ab- 
domen 4700  c.c.  of  fluid  were  withdrawn.  It  was  clear,  yellowish, 
with  a  specific  gravity  of  1016,  sediment  mostly  lymphocytes. 


Fig.  253. — Signs  in  the  back  on  January  19,  191 2  (Case  316). 


Discussion. — In  all  probabiHty  the  patient's  pain  in  the  right  flank 
and  back,  the  pain  which  she  has  had  for  ten  years,  has  no  connection 
with  her  present  troubles,  and  may  very  possibly  represent  the  results 
of  some  traumatic  strain  or  sprain. 

We  may  reasonably  suppose  that  the  problem  now  to  be  solved 
is  the  cause  of  the  five  weeks  of  painful  abdominal  enlargement,  with 
dyspepsia,  vomiting,  loss  of  flesh  and  strength.  At  her  age  this  is  an 
alarmmg  group  of  symptoms,  as  physical  examination  shows  a  mass 
occupying  the  usual  site  of  the  kidney  or  liver.  Its  possible  connection 
with  the  kidney  is  further  hinted  at  by  the  painful  urination.     On  the 


702 


DIFFERENTIAL   DIAGNOSIS 


other  hand,  the  negative  condition  of  the  urine  points  against  this,  and 
the  outline  of  the  mass,  as  seen  in  Figs.  253  and  254,  certainly  suggests 
liver  rather  than  kidney. 

The  fluid  obtained  by  tapping  has  the  specific  gravity  generally 
associated  with  malignant  disease  or  tuberculosis.  Against  tubercu- 
losis is  the  size  and  situation  of  the  tumor,  the  absence  of  fever,  and  the 
presence  of  leukocytosis;  also  the  patient's  age. 

Syphilis  is  suggested  by  the  apparently  nodular  surface  of  the  mass 
in  the  hepatic  region.     The  negative  Wassermann  reaction  tends  to 


Fig.  254. — Abdominal  mass  as  outlined  on  January  20,  1912. 


exclude  this,  but  does  not  absolutely  do  so.  If  it  were  a  S3phiLitic 
liver,  we  should  expect  enlargement  of  the  spleen  and  possibly  some 
fever. 

If  all  these  possibilities  are  excluded,  cancer  of  the  liver  remains 
as  the  most  probable  diagnosis.  Such  cancer  is  usually  secondary  to  a 
gastric  neoplasm,  and  the  history  seems  to  begin  with  gastric  symptoms. 
Such  a  diagnosis  will  explain  everything  except  the  brownish  color  of 
the  skin.  That  color  is  compatible  with  any  of  the  diagnoses  which 
we  have  considered,  but  characteristic  of  none.  It  remains  un- 
explained. 


ASCITES   AND   ABDOMINAL   ENLARGEMENT  703 

Outcome. — Dr.  W.  M.  Conant  advised  against  operative  inter- 
ference. Antisyphilitic  medication  had  no  effect.  The  patient  left 
the  hospital,  unrelieved,  on  the  26th. 

Case  317 

A  housewife  of  fifty-nine  entered  the  hospital  October  31,  191 1. 
The  patient's  chief  complaint  is  of  abdominal  enlargement  and  of 
stomach  trouble.  Her  father  died  of  shock,  one  brother  of  enlarged 
liver  and  ascites.  Two  other  brothers  and  one  sister  died  in  infancy. 
Her  husband  has  recently  had  two  operations  for  rectal  fistula.  The 
patient  has  three  living  children  and  has  had  three  miscarriages,  but, 
save  for  an  attack  of  bronchitis  two  years  ago,  has  never  been  sick. 
She  entered  the  hospital  with  a  diagnosis  of  "cirrhosis  of  the  liver." 
She  takes  tea  in  very  large  amounts,  often  2  quarts  a  day.  She  denies 
alcohol.     The  menopause  occurred  fourteen  years  ago. 

The  abdominal  enlargement  was  first  noticed  six  months  ago,  and 
her  clothes  began  to  seem  notably  tight  about  her  waist.  Since  then 
the  abdomen  has  uniformly  and  very  gradually  increased  in  size. 
Occasionally  she  has  rather  sharp  pains  of  a  few  minutes'  duration, 
running  from  the  flanks  either  toward  the  navel  or  toward  the  pelvis. 
These  pains  do  not  appear  to  be  related  to  food,  to  the  time  of  day,  or 
to  the  state  of  her  bowels. 

For  about  six  years  she  has  had  attacks  of  what  she  calls  ''indiges- 
tion," coming  from  once  a  month  to  once  in  three  months,  lasting  about 
three  days.  In  these  attacks  she  loses  her  appetite,  has  nausea,  and 
usually  some  vomiting,  but  no  pain  or  jaundice.  These  attacks  have 
not  increased  either  in  frequency  or  in  severity.  In  the  intervals 
between  them  she  has  occasional  epigastric  distress  and  eructations  of 
gas.  She  has  never  vomited  blood  and  has  never  had  any  morning 
nausea  or  vomiting.  For  the  past  six  months  she  has  noticed  slight 
edema  of  the  lower  legs  at  night  and  frequent  cramps  in  the  calves  and 
thighs,  sometimes  waking  her  from  sleep.  During  the  past  year  she 
has  passed  urine  once  to  thrice  in  the  night  and  very  frequently  in  the 
daytime.  Occasionally  urine  is  passed  involuntarily.  She  has  no 
cough,  no  shortness  of  breath.  Bowels  are  usually  constipated,  with 
occasional  attacks  of  diarrhea.  She  does  not  know  her  exact  weight, 
but  thinks  she  has  become  a  Httle  thin.  She  has  had  no  fever  or  night- 
sweats. 

Physical  examination  showed  an  obese,  nervous  old  lady.  The 
heart's  apex  reached  i  cm:  outside  the  midclavicular  line.  There  was  a 
soft  systolic  murmur,  best  heard  along  the  left  sternal  margin.     The 


704  DIFFERENTIAL  DIAGNOSIS 

aortic  second  was  sharp  and  accentuated.  The  radial  arteries  showed 
thickening.  Systolic  blood-pressure,  150  mm.  Hg. ;  diastoKc,  80  mm. 
Hg.  Blood  and  urine  normal.  Lungs  normal.  The  abdomen  was  full 
and  distended;  tjonpanitic  between  the  navel  and  the  ensiform.  Liver 
and  spleen  not  felt.  At  entrance  there  seemed  to  be  some  shifting 
dulness  in  the  flanks,  but  the  next  morning  this  could  not  be  demon- 
strated and  it  was  not  observed  thereafter.  The  stomach-tube  showed 
no  contents  in  the  fasting  stomach.  Capacity  of  the  organ  was  1800 
c.c.  After  a  test-meal  stomach  contents  showed  free  HCl  .046;  total 
acidity,  .083  per  cent.     Guaiac  negative.     Feces  negative. 

Discussion. — The  history  is  of  six  months'  abdominal  enlargement 
in  a  woman  of  fifty-nine  with  dyspeptic  symptoms  and  slight  edema 
of  the  lower  legs.  Physical  examination  does  not  demonstrate  the 
presence  of  any  fluid  or  of  any  solid  tumor  in  the  abdomen.  The 
results  of  gastric  analysis  are  practically  negative.  There  is  no  gas- 
eous distention,  though  a  small  area  of  tympany  is  to  be  marked  out 
high  up  above  the  navel. 

Judging  from  the  cramps,"  the  rather  high  systolic  blood-pressure 
and  pulse-pressure,  and  the  thickening  of  the  radial  arteries,  we  may 
conjecture  that  she  has  some  arteriosclerosis.  That  is  very  natural 
at  her  age,  but  it  is  not  at  all  probable  that  this  accounts  for  any  ab- 
dominal enlargement,  although  it  may  well  account  for  abdominal 
discomfort.  On  the  whole,  the  best  judgment  that  we  could  make  in 
this  case  was  that  the  patient  was  fat,  but  otherwise  fairly  healthy. 

Outcome. — The  patient  went  home  on  the  6th  with  a  diagnosis  of 
obesity.  On  February  12,1913,  her  daughter  wrote  that  she  was  quan- 
titatively and  qualitatively  about  the  same.  She  still  has  cramps  off 
and  on. 


INDEX 


[Words  and  page  numbers  printed  in  heavy  type  correspond  to  illustrative  cases;  other 
words  and  numbers,  to  minor  discussions.] 


Abdominal  enlargement,  649-704 

Abscess,  axillary,  70,  597 

pulmonary,  448 

after  tonsillectomy,  453 

of  spleen,  584 

subdiaphragmatic,  584 
Acid-fast  organisms,  440 
Actinomycosis,  64,  421 
Addison's  disease,  148,  164,  340 
Adenitis,  cervical,  393 

septic,  389 

syphilitic,  47 

tuberculous,  401,  402 
Adhesions,  346 

harmlessness  of,  212,  241,  300 
Alcoholic  neuritis,  465 

AlcohoUsm,   151,  215,  302,  321,  417,  483, 
485,  544,  642 

tremor  in,  639 
Alternation,  625 

Amebic  dysentery.     See  Dysentery. 
Amoeba  coli  and  the  pathogenic  amebae,  224 
Anemia  in  cancer,  334 

myelophthisic,  579 

pernicious,  231,  233,  334,  471,  554,  582, 
587,  592,  595,  631 
diagnosis  of,  472 
edema  of  face  in,  418 

pulsating  tumors  in,  234 

secondary,  577,  696 

splenic,  367 
Aneurysm,  92,  141,  434,  569,  571,  572 

aortic,  566 
Angina  Ludovici,  429 

pectoris,  255 
Angioma,  61 

Antrum,  empyema  of,  424 
Aortitis,  syphilitic,  387,  594,  602 
Aphonia,  hysteric,  563 
Appendicitis,  197 

chronic,  275,  686 
45 


Arhythmia,  622-638 

causes  of,  622,  624 

sinus,  623,  636 
Arm,  swelling  of,  597-611 

causes  of,  597 
Arteriosclerosis,    154,    162,    165,   317,   320, 
487,  488,  518,  544,  550,  704 

cerebral,  551,  553,  617,  625 
Ascites,  17,  649-704 

causes  of,  649 

fibromyoma  of  uterus,  655 

gaseous  distention  in,  690,  698 

ovarian  tumor,  655 

rate  of  accumulation  in,  654 
Ataxia,  vasomotor,  427  * 

Bacillus  coli,  infection  with,  202 
Bence- Jones'  body,  395 
Bilharzia  disease,  225,  414.     See  also   Rec- 
tum. 
Bladder,  stone  in,  504 
Blood  in  stools.     See  Melena. 
Blood-pressure,  border-line  readings  of,  480 
Bothriocephalus  latus,  anemia,  595 
Brain  tumor,  544 
Branchial  cyst,  375,  376 
Bronchitis,  306 

Cancer  of  appendix,  115 
of  bladder,  196 
of  cecum,  85,  115 
chronicity  of,  36 
diffuse,  of  peritoneum,  235 
of  gall-bladder,  272,  292 
of  intestine,  181,  256 
multiple,  of  skin,  62 
of  ovary,  41 
rectal,  409 
of  sigmoid,  201 

of  stomach,  100,  103,  235,  268,  329,  336, 
341,  354,  413,  577,  700 

705 


7o6 


INDEX 


Cancer  of  thyroid,  380 

uf  \'aler's  papilla,  2S2 
Cerebellar  cyst,  154 

tumor,  167 
Cerebral  tumor,  145,  167,  257,  276 
Cervical  rib,  37 
Chlorosis,  311,  581,  620 
Cirrhosis,  360,  364 

hepatic,  609,  670,  673,  676,  680,  688 
hydrothorax  in,  670 
Coccidioidal  disease,  63 
Colitis,  176,  182,  211,216,219,  243,248,  306 

infectious,  200 

mucous,  1 84,  241 

tuberculous,  216 

ulcerative,  248,  412 
Coma,  hysteric,  542 
Congenital  heart  disease.     See  Heart. 
Constipation,  211,  240,  277,  289 
Cystitis  of  streptococcus  origin,  500 

Delirium,  612-621 

causes  of,  612 

in  children,  612 

postfebrile,  616,  618 

tremens,  612 
Dementia  paralytica,  145 
Diabetes,  complicating,  540 
Diarrhea,  175-249 

acute  and  chronic,  176,  185 

alimentary,  207,  215 

causes  of,  176,  178 

infectious,  200 

morning,  181 

nervous,  194,  206 

proctoscopy  in,  183 

prognosis  of,  184 

stools  in,  183 

t>^es  and  diagnosis,  183 

of  unknown  cause,  214,  246 
Diet,  bad,  288,  327 

in  diarrhea,  178 
Digestion,  inhibition  of,  258 
Diverticulitis  perforating  the  bladder,  498 
Drug  eruptions,  419 
Dry  skin  in  pyloric  stenosis,  338 
Duodenal  ulcer.     See  Peptic  ulcer. 
Dysentery,  acute  bacillary,  488 

amebic,  223,  244,  415 
Dyspepsia,  250-349 

after  forty,  causes  of,  265 

causes  of,  250,  257 

nervous,  344 


Dyspepsia  in  phthisis,  307,  332 

unknown  cause,  293,  326 

Echinococcus  of  liver,  29,  132 
Edema,  angioneurotic,  419,  426 

of  face,  417-431 

of  legs,  465-493 

causes  of,  465 
Elephantiasis,  466,  489 

operation  for,  491 
Emaciation  (lcsi)ite  good  appetite,  267 
Endocarditis,  acute,  220 

mitral,  235 

and  aortic,  221,  476 

and  nephritis,  223 

streptococcic,  476,  547,  593 
Epileps}',  minor,  542 
Erysipelas,  425 
Erythema  multiforme,  482 

nodosum,  60 
Exostoses,  multiple,  63 

Fainting,  541-557 

causes  of,  541 
Fat,  intolerance  of,  179,  190 
Fecal  impaction,  130 
Fever  after  hemorrhage,  314 

unknown  cause,  296 
Fibromyoma  of  uterus,  28,  31,  346,  695 

uterine,  ascites  in,  655 
Flat-foot,  470 
Frequency  due  to  psychic  causes,  518 

in  dajlime,  501 

from  habit,  505 

nervous,  501 

with  antiflexion,  502 
Frequent  micturition  and  polyuria,  495-540 
causes  of,  495 

Gall-stones,  116,  255,  274,  318 
Gaseous  distention  of  intestine,  698 
Gastric  cancer.     See  Cancer. 

dilatation,  an  entity,  271 
tests  for,  261,  271 

symptoms  in  hydronephrosis,  280 
Gland  puncture,  374 
Glanders,  52,  64 
Glands,  369-405 

drainage  areas,  369 

enlarged,  369 

septic,  389 

and  what  stimulates  them,  374 
Glandular  enlargements,  four  tj^Des,  373 


INDEX 


707 


Glandular  tumors,  nomenclature  of,  374 
Glomerulonephritis,  chronic,  464,  480,  517 
subacute,  487 

Gumma.     See  Syphilis. 

Heart  disease,  congenital,  440 
Heat  stroke,  150 
Hematemesis,  332,  350-368 

causes  of,  350 
Hemophilia,  358 
Hemoptysis,  432-464 

causes  of,  432 

and  malingering,  458 

from  stomatitis,  458 

tuberculous,  432,  463 
Hemorrhage  in  cirrhosis,  361 
Hepatic  cirrhosis,  487 
Hepatitis,  interstitial.     See  Cirrhosis. 
Hereditary  trophedema,  466 
Hoarseness,  559-574 

causes  of,  559 
Hydrocephalus,  internal,  359 
Hydronephrosis,  280,  503 

intermittent,  51 
Hypernephroma,  39,  41,  49,  125,  126,  382, 

387 
Hysteria,  153,  157,  271,  427,  556,  557,  619, 

646 
Hysteric  aphonia,  559,  563 

Infarct,  pulmonary,  434 
Intussusception,  181 

Jaundice,  hemolytic,  no 

Kidney,  stone  in,  119,  288 

Labyrinthine  disease,  147,  173 

Labyrinthitis,  specific,  387 
Laryngeal  syphilis,  562 
Laryngitis,  559,  561 

psychic  factors  in,  559 

syphilitic,  428.     See  also  Syphilis. 
Larynx,  papilloma  of,  567 
Lead-poisoning,  164,  256,  286,  320,  640,  688 
Leather-bottle  stomach,  235 
Leprosy,  65 
Leukemia,  33,  70,  72,  334 

lymphoid,  383,  386,  398,  579 
Leukopenia,  399 
Lines  albicantes,  355,  356 
Lipomatosis,  58,    76 

Liver,  cirrhosis  of,  283,  310,  352,  359,  466 
Liver,  corset  lobe  of,  34 


Lumps  under  skin,  54 

Lung,  gangrene  of,  455 

Lymphadenoid  tissue,  minute  collections  of, 

372 
Lymphoblastoma,  47,  69,  72, 74, 90, 127, 189, 
192,  378,  381,  38O,  387,  394,  405,  684 

of  skin,  61,  130 

types  of,  394 

Malaria,  621 

tertian,  420 
Malingering,  460 

Mediastinal  tumor,  560,  569,  597,  601 
Helena,  406-416 

causes  of,  406 
Meniere's  syndrome,  171 
Mitral  disease,  hemoptysis  in,  435 

stenosis,  235,  352,  629,  637,  647 
Morphinism,  228 
Multiple  sclerosis,  640,  648 
Mumps.     See  Parotitis. 
Mural  thrombi,  518 
Myeloma,  125,  382,  396 
Myocardial  weakness,  160 
Myomalacia,  518 
Myositis,  64 
Myxedema,  419,  466 

Nephritis,  139,  142,  152,  181,  221,  251,  264, 
278 
acute,  427,  484,  494 
glomerular,  589 

amyloid,  306 
chronic,  468 
vascular,  430 

edema  of  face  in,  417 

endocarditis,  223 

glomerular,  547,  679,  691 

streptococcus,  484 
Nephroptosis,  34 
Neurasthenia,  193,  323 
Neuritis,  simple,  644 
Neuroblastoma,  390 
Neurofibromatosis,  56 
Night-sweats,  363 

Obesity,  703 

Old  age,  diseases  of,  329. 

Osteitis  deformans,  41 

Osteomyelitis,  599 

Otitis  media,  200,  614 

Ovarian  tumor,  ascites  in,  655 

Ovary,  cancer  of,  45 


7o8 


INDEX 


Ovary,    cystadenoma  of,  31,  43,  344,  6€'8, 
682, 6o6,  699 
fibroma  of,  353,  678 

Pallor,  575-596 

causes  of,  575 
Palpitation,  622-638 

causes  of,  622 
Pancreas,  cancer  of,  75 
Paralysis  ajntans,  640 
Parkinson's  disease,  640,  643 
Parotitis,  421 

septic,  421 
Pellagra,  611 

Pel\-ic  abscess,  retroperitoneal,  499 
Peptic  ulcer  (gastric  or  duodenal),  259,  311, 

314,  352,  350,  364,  365,  546,  591 
Pericarditis,  chronic  adhesive,  609,  665,68! 

terminal,  518 

tuberculous,  606 
Periostitis,  sj'philitic,  58 
Peritonitis,  chronic,  321 

tuberculous,  80,  103,  198,  209,  493,  509, 
675,  679,  686,  688,  689,  698 
Phantom  tumors,  122 
Phlebitis,  465,  469,  477,  597,  598,  601,  602, 

606,  609 
Phthisis,  435,  440,  444,  452,  461,  462,  492 
Plumbism.     See  Lead. 
Pneumaturia,  498 
Pneumonia  with  hemoptysis,  442 
Portal  thrombosis,  686 
Pregnancy,  27,  251,  284,  417 

ectopic,  77 
Proctoscopy,  183 
Psychic  diagnosis,  42 

factors  in  dyspepsia,  257 
Psychoneurosis,  323 
Psychotherapy,  505 
"Ptomain-poisoning,"  179,  686 
Pulmonary  abscess,  448.  See  also  Abscess. 

apoplexy,  464 

embolism,  septic,  450 
Pyelonephritis,  508 
Pylephlebitis,  686 
Pyloric  spasm,  316 
Pyonephrosis,  120,  287 

Rectal  stricture,  237 
Rectum,  bilharziasis  of,  414 

cancer  of.     See  Cancer. 
Renal  tuberculosis,  513 

pain  and  tumor  in,  512 


Rest,  benefits  of,  345 

dangers  of,  324 
Retroversion,  vomiting  in,  361 
Rheumatic  nodes,  59 
Rib,  cervical,  39 

Salicylates,  delirium  from,  613 
Salvarsan  in  pernicious  anemia,  588 
Sarcoma,  melanotic,  of  liver,  124 
Sclerosis,  multiple,  640 
Scurvy,  64 
Sepsis,  59 

Skin  lesions  associated  with  edema,  417 
Social  maladjustment,  304,  312,  325 
Somnolence  in  trichiniasis,  242 
Splenic  anemia.     See  Anemia,  splenic. 
Sputum  inoculation,  440,  461 
Staphylococcus  vaccine,  389 
Starvation,  211,  345 

causing  dyspepsia,  254 
Stenosis,  mitral,  629,  637 
Stockton,  C.  G.,  139 
Stokes-Adams'  disease,  553 
Stomach,  cancer  of.     See  Cancer. 

ulcer  ot.     See  Peptic  ulcer. 
Stone  in  bladder,  504 

in  kidney,  288 
Stools,  examination  of,  183 

pus  in,  188 
Sunstroke,  150 

Surgery,  meddlesome,  205,  300 
Swelling  of  arm,  597-611 
causes  of,  597 

of  face,  417-431.     See  also  Edema. 
causes  of,  417 
SyphiUs, 79, 87, 93, 94,  97, 105, 107, 150, 153, 
155,  157,  172,  237,  310,  571, 582,  644 

cardiac,  hepatic,  and  cerebrospinal,  481 

cerebrospinal,  392 

hepatic,  657,  673,  683,  688,  702 

of  larynx,  429,  574 

renal,  660,  662 
Syphilitic  aortitis,  387 

Tabes,  228,  255,  291,  316,  322,  348,  363 

surgical  blunders  in,  229 

varieties  of  bellyache  in,  256 
Tachycardia,  neurotic,  626,  635,  636 

paroxysmal,  623,  627 
Tetany,  269 
Thrombosis,  cerebral,  620 

of  inferior  cava,  29 

portal,  686 


INDEX 


709 


Thyroid,  cancer  of.     See  Cancer. 
Thyrotoxicosis,  622,  626,  627,  628,  633,  637 

tremor  in,  639 
Tobacco,  palpitation  from,  635 
Tonsillar  inflammation,  origin  of,  372 
Transfusion,  367,  368 
Tremor,  639-648 

causes  of,  639 

senile,  639 
Trichiniasis,  241,  422 

facial  edema  of,  418 

with  general  edema,  473 

technic  of  blood  examination  in,  423 
Tuberculin,  326 
Tuberculosis,  251,  540 

cecal,  186 

of  ileum,  493 

of  intestine,  180,  189,  215,  219 

miliary,  159,  169,  492 

with  mitral  stenosis,  438 

pulmonary,  307,  321,  326,  332,  510 

renal,  511,  513 

of  skin,  58 

of  spine,  326 
Tuberculous  peritonitis,  80,  103,  198,  209, 

493,  509,  675,  679,  686,  688,  689,  698 


Tumors,  abdominal,  17,  189 

diagnosis  of,  17-133 

phantom,  67,  122 
Typhoid    fever,    146,    202,    239,  247,  410, 
614 

infection  in  gall-bladder,  508 
Typhus  fever,  202,  419 

UllEMIA,  618 
Urticaria,  60 

Varicose  veins,  465 
Vascular  crisis,  550,  553 
Vertigo,  134-174 

aural,  137,  147,  171,  173 

in  brain  disease,  136,  162 

causes  of,  135 

of  circulatory  origin,  161 

in  epilepsy,  138 

neurotic,  137 

pathologic,  136 

physiologic,  134 

toxic,  139 
Vomiting  at  menstruation,  361 

treatment  of,  269 


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many  details  so  often  left  to  the  imagination." 

ChEO-les  B.  Penrose,  M.  D. 

Formerly  Professor  of  Gynecology  in  the  University  of  Pennsylvania 

"  I  know  of  no  book  that  goes  10  thoroughly  and  satisfactorily  into  all  the  details  of  every- 
thing connected  with  the  subject.     In  this  respect  your  book  differs  from  the  others." 

George  M.  Edebohls.  M.  D. 

Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical  School 
"A  text-book  most  admirably  adapted  to  teach  gynecology  to  those  who  must  get  theil 
icnowledge,  even  to  the  minutest  and  most  elementary  details,  from  books." 


GYNECOLOGY  AND    OBSTETRICS 


Bandler*s 
Medical    Gynecology 


Medical  Gynecology.  By  S.  Wyllis  Bandler,  M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  790  pages,  with  150  original  illus- 
trations.    Cloth,  $5.00  net;  Half  Morocco,  ^6.50  net 

NEW  (3d)  EDITION— 60  PAGES  ON  INTERNAL  SECRETIONS 

This  new  work  by  Dr.  Bandler  is  just  the  book  that  the  physician  engaged  in 
general  practice  ha§  long  needed.  It  is  truly  the  practitioner' s  gynecology — planned 
for  him,  written  for  him,  and  illustrated  for  him.  There  are  many  gynecologic 
conditions  that  do  not  call  for  operative  treatment ;  yet,  because  of  lack  of  that 
special  knowledge  required  for  their  diagnosis  and  treatment,  the  general  practi- 
tioner has  been  unable  to  treat  them  intelligently.  This  work  not  only  deals 
with  those  conditions  amenable  to  non-operative  treatment,  but  it  also  tells  how  to 
recognize  those  diseases  demanding  operative  treatment. 

American  Journal  of  Obstetrics 

"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily 
grasped  by  the  general  practitioner." 


Handler's  Vaginal   Celiotomy 

Vaginal  Celiotomy.  By  S.  Wyllis  Bandler,  M.  D.,  New  York 
Post-Graduate  Medical  School  and  Hospital,  Octavo  of  450  pages,  with 
148  original  illustrations.     Cloth,  I5.00  net;  Half  Morocco,  $6.50  net. 

SUPERB  ILLUSTRATIONS 

The  vaginal  route,  because  of  its  simplicity,  ease  of  execution,  absence  of 
shock,  more  certain  results,  and  the  opportunity  for  conservative  measures,  con- 
stitutes a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and  obstetricians. 
Posterior  vaginal  celiotomy  is  of  great  importance  in  the  removal  of  small  tubal 
and  ovarian  tumors  and  cysts,  and  is  an  important  step  in  the  performance  of 
vaginal  myomectomy,  hysterectomy,  and  hysteromyomectomy.  Anterior  vaginal 
celiotomy  with  thorough  separation  of  the  bladder  is  the  only  certain  method 
of  correcting  cystocele. 

The  Lancet,  London 

"  Dr.  Bandler  has  done  good  service  in  writing  this  book,  which  gives  a  very  clear  descrip- 
tion of  all  the  operations  which  may  be  undertaken  through  the  vagina.  He  makes  out  a 
strong  case  for  these  operations." 


SAUNDERS'    BOOKS   ON 


Kelly  and   Noble*s 

Gynecology 

am)  Abdominal  Surgery 


Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University  ; 
and  Charles  P.  Noble,  M.  D.,  formerly  Clinical  Professor  of  Gyne- 
cology in  the  Woman's  Medical  College,  Philadelphia.  Two  imperial 
octavo  volumes  of  950  pages  each,  containing  880  illustrations,  some  in 
colors.     Per  volume:   Cloth,  $8.00 net ;  Half  Morocco,  ^9.50  net. 

TRANSLATED  INTO  SPANISH 
WITH   880   ILLUSTRATIONS    BY  HERMANN   BECKER   AND   MAX   BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  of 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
cology, dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  medical  gynecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdommal  surgery  proper,  as  distinct  from  gynecology,  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  Hver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  peritoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr. 
Hermann  Becker  and  Mr.  Max  Brodel. 

Americzui  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done:  the  names  of  the  authors 
and  editors  would  guarantee  this ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  not  to  be  found  elsewhere." 


C  YNECOLOG  V  AND  OBSTETRICS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text=Book  of  Obstetrics.      By  J.   Clarence  Webster,    M.    D 
(Edin)  F   R  C   P   E.   Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago       Octavo 
volume   of  767    pages,  illustrated.     Cloth,   ^5-00   net;   Half  Morocco, 
^6.50  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  '  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  importance  in  their  relation  to  obstetrics. 

„,„.  ,fb.  desired,  i.  being  „  near  perfection  as  an,  con,pae,  work  .ha,  has  been  pubhsh.d. 


Webster's 
Diseases  of  Women 

A  Text=Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M  D  (Edin.),  F.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.  Cloth,  $7.00  net ;  Half  Morocco,  ^8.50  net. 
Dr  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  clinical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  speciaUsm.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  are  nearly  all  original. 

Howard  A.  Kelly.  M.  D.  ,.  .        . 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  Umverstty. 

MUs  undouMedlv  one  of  the  best  works  wh>ch  has  been  put  on  the  market  wUhm  recen 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order." 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 


The  New  (7th)  Edition 


A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  Univer.sit\-  of  Pennsylvania.  Handsome 
octavo  of  1013  pages,  with  895  illustrations,  53  of  them  in  colors. 
Cloth,  ^5.00  net ;   Half  Morocco,  $6.50  net. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospital 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES    OF    WOMEN. 


HirstV 
Diseases  of  Women 


A  Text=Book  of  Diseases  of  Women.  By  Barton  Cookk  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania  ;  Gynecolo- 
gist to  the  Howard,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  ;^5.oo  net;  Half  Morocco,  ^6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  clinical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  v;ithout  referring  them  to  a  specialist.  An  entire  sec- 
tion is  devoted  to  ?.  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  extensive  ex- 
perience renders  i;his  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"  Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

"The  author  has  given  special  attention  to  diagnosis  and  treatment  throughout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"  Oflfice  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


GET  ^  «  THE  NEW 

THE  BEST  /\  m  C  r  I  C  Si  n  standard 

Illustrated   Dictionary 

New  (7th)  Edition— 5000  Sold  in  Two  Months 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  loonew  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "The 
American  Pocket  Medical  Dictionary."  Large  octavo,  1107  pages, 
bound  in  full  flexible  leather.  Price,  $4..1)0  net;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— MANY  NEW  FEATURES 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  new  terms  are  live, 
active  words,  taken  right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature 
of  the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 

In  the  '  'American  Illustrated ' '  practically  every  word  is  given  its  derivation. 

Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a  word 

ciuickly. 

The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the  greatest  help 
in  assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the 
necessary  information  about  the  various  structures. 

Every  word  is  given  its  definition — a  definition  that  defines  in  the  fewest  pos- 
sible words.  In  some  dictionaries  hundreds  of  words  are  not  defined  at  all,  refer- 
ring the  reader  to  some  other  source  for  the  information  he  wants  at  once. 

Howard  A.  Kelly,  M.  'D.,  Johns  Hopkins  University,  Baltimore 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  ol 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AND    OBSTETR/CS 


Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text=Book  of  Diseases  of  Women.  By  Charles  B,  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  in  the  University  of 
Pennsylvania ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.     Cloth, 

^3.75  net. 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted  and  made  clear  by  excellent  illustrations. 

Howard  A.  Kelly.  M.D.. 

Professor  of  Gyftecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.     I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." 


Davis*  Operative  Obstetrics 

operative  Obstetrics.  By  Edward  P.  Davis,  M.D.,  Professor  of 
Obstetrics  at  Jefferson  Medical  College,  Philadelphia.  Octavo  of  483 
pages,  with  264  illustrations.     Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

INCLUDING  SURGERY  OF  NEWBORN 

Dr.  Davis'  new  work  is  a  most  practical  one,  and  no  expense  has  been  spared 
to  make  it  the  handsomest  work  on  the  subject  as  well.  Every  step  in  every 
operation  is  described  minutely,  and  the  technic  shown  by  beautiful  new  illustra- 
tions.    Dr.  Davis'  name  is  sufficient  guarantee  for  something  above  the  mediocre. 


H  SAUNDERS'    BOOKS   ON 

Dorland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.  By  W.  A.  Newman 
Borland,  A.  M.,  M.  D.,  Professor  of  Obstetrics  at  Loyola  University, 
Chicago,  Illinois.  Handsome  octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  $4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Journal  of  the  American  Medical  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Ob.stetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  480  pages,  illustrated.     Buckram,  ^1.75  net. 

NEW  (4th)  EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

••  Not  onlv  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  '3 

Kelly  and  Cullen*s 
Myomata   of  the  Uterus 


Myomataof  the  Uterus.  By  Howard  A.  Kelly,  M.  D.,  Professor 
of  Gynecologic  Surgery  at  Johns  Hopkins  University;  and  Thomas  S. 
CuLLEN,  M.  B.,  Associate  in  Gynecology  at  Johns  Hopkins  University. 
Large  octavo  of  about  700  pages,  with  388  original  illustrations,  by 
August  Horn  and  Hermann  Becker.  Cloth,  $'J.'^o  net ;  Half  Morocco, 
;^9.oo  net.  "  ' 

ILLUSTRATED     BY     AUGUST     HORN     AND     HERMANN     BECKER 

This  monumental  work,  the  fruit  of  over  ten  years  of  untiring  labors,  will 
remain  for  many  years  the  last  word  upon  the  subject.  Written  by  those  men 
who  have  brought,  step  by  step,  the  operative  treatment  of  uterine  myoma  to 
such  perfection  that  the  mortality  is  now  less  than  one  per  cent.,  it  stands  out  as 
the  record  of  greatest  achievement  of  recent  times. 

Surgery,  Gynecology,  and  Obstetrics 

"  It  must  be  considered  as  the  most  comprehensive  work  of  the  kind  yet  published.  It 
will  always  be  a  mine  of  wealth  to  future  students." 


Cullen's  Adenomyoma  of  the  Uterus 

Adenomyom.a.  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.  Octavo  of  275 
pages,  with  original  illustrations  by  Hermann  Becker  and  August  Horn.  Cloth, 
^5.00  net;  Half  Morocco,  $6.50  net. 

"A  good  example  of  how  such  a  monograph  should  be  written.  It  is  an  excellent 
work,  worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  which  it 
emanates." — The  Lancet,  London. 

Cullen's  Cancer  of  the  Uterus 

Cancer  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.  Large  octavo  of  693 
pages,  with  over  300  colored  and  half-tone  text-cuts  and  eleven  lithographs.  Cloth, 
^7.50  net  ;  Half  Morocco,  $8.50  net. 

"  Dr.  Cullen's  book  is  the  standard  work  on  the  greatest  problem  which  faces  the 
surgical  world  to-day.  Any  one  who  desires  to  attack  this  great  problem  must  have 
this  book." — Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University. 


14  SAUNDERS'    BOOKS   ON 

Schaffer  and  Edg(ar's  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome  of    Labor    and    Operative    Obstetrics.      By    Dr. 

O.  ScHAri-ER,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D. ,  Professor  of  Obstetrics  and  Clinical  .Midwifery,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.      Cloth,  3^2.00  net.     In  Saunders   Hand-Atlases. 


Schaffer     and     Edgar's     Obstetric      Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.    By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School,  New  York.  With  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315  pages  of  text.      Cloth,   #3.00  net.      Saunders'  Hand-Atlases. 


Schaffer  and  Norris'  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C,  Norris,  A.  M.,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text.  Cloth, 
^3.50  net.      In  Saunders'  Hand-Atlas  Series. 


Galbraith's  Four  Epochs  of  Woman's   Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
M.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  John  H.  Musser,  M.  D.,  University  of 
Pennsylvania.      i2mo  of  247  pages.      Cloth,  $1.50  net. 

Birmingham  Medical  Review,  England 

"  We  do  not,  as  a  rule,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


Garrigues*  Diseases  of  Women  Third  Edition 

A  Text=Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues,  M.  D., 
Gynecologist  to  St.  Mark's  Hospital,  New  York  City.  Octavo  of  756  pages, 
illustrated.      Cloth,  $4. 50  net  ;    Half  Morocco,  $6.00  net. 


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